Foundations and Adult Health Nursing Test Bank

Correct Answer: B

Rationale: Leaving the side rails down is one of the most common occurrences that can lead to a patient fall. Side rails are important safety measures designed to prevent patients from falling out of bed. When the side rails are left down, the patient is at a higher risk of accidentally rolling out of bed and falling. It is crucial for healthcare providers to always ensure that the side rails are up and secure to help prevent patient falls.

Correct Answer: B

Rationale: For a displaced femoral neck fracture, the most appropriate surgical procedure is usually an open reduction and internal fixation (ORIF). This procedure involves making an incision to reposition the fractured bone fragments and securing them in place with screws or other fixation devices. ORIF allows for better alignment of the fracture, which is crucial for proper healing and minimizing the risk of complications like avascular necrosis or nonunion. Closed reduction and internal fixation (CRIF) may not be as effective for displaced femoral neck fractures due to the complex nature of the fracture and the need for precise realignment and stability provided by an open surgical approach. External fixation is less commonly used for femoral neck fractures and is typically reserved for certain specific cases where internal fixation is not feasible. Closed reduction alone is unlikely to provide adequate stability for a displaced femoral neck fracture and is generally not recommended as the primary surgical treatment for this type of injury.

Correct Answer: A

Rationale: Assessing the infant's latch and feeding effectiveness should be prioritized as the initial nursing intervention to address the client's concerns about inadequate milk supply. Poor latch can lead to ineffective milk removal, which may result in decreased milk production. By ensuring the infant is latching correctly and effectively transferring milk, the client's milk supply can be optimized. Education about techniques to increase milk production can be provided following the assessment of feeding effectiveness. Referring to a lactation consultant may be necessary for further evaluation and support if issues persist despite correcting the latch. Supplemental formula feedings should be recommended as a last resort after all other interventions have been attempted and if there are concerns about inadequate nutrition for the infant.

Correct Answer: A

Rationale: Pre-eclampsia is a serious condition that can occur during pregnancy, usually after 20 weeks gestation. It is important to screen for pre-eclampsia early in the pregnancy to monitor and manage the condition effectively. Screening for pre-eclampsia typically begins in the first trimester of pregnancy to identify any risk factors and provide appropriate care for the patient. Therefore, Nurse Vera informing the patient to get screened for pre-eclampsia in the first term of pregnancy is the most appropriate time to start monitoring for this condition.

Correct Answer: A

Rationale: Attention deficit hyperactivity disorder (ADHD) is characterized by inattentiveness, overactivity, and impulsiveness. Individuals with ADHD may have difficulty paying attention, completing tasks, sitting still, or controlling their impulses. Mental retardation (now referred to as intellectual disability) is a separate condition characterized by limitations in intellectual functioning and adaptive behaviors. While individuals with ADHD may experience difficulties in school or work due to their symptoms, ADHD itself does not indicate mental retardation.