Foundations and Adult Health Nursing Test Bank

Correct Answer: A

Rationale: In the case of Romy being diagnosed with small cell lung cancer (SCLC) and undergoing palliative treatment, the most appropriate nursing action is to focus on providing relief from symptoms. Palliative care aims to improve the quality of life for patients with serious illnesses by managing their symptoms, such as pain, shortness of breath, nausea, and other side effects of treatment. As the cancer is advanced and the goal is not curative treatment but rather to keep the patient comfortable, symptom management becomes a priority to ensure Romy's physical comfort and well-being during this difficult time. Providing relief from symptoms is crucial in palliative care to help enhance the patient's quality of life and ensure they are as comfortable as possible.

Correct Answer: B

Rationale: Digoxin is a medication commonly used in the treatment of congestive heart failure because it helps to improve cardiac output and reduce heart failure symptoms. One of the desired effects of digoxin is an increase in urinary output. This is because digoxin helps to improve cardiac function, which can lead to better circulation and increased kidney perfusion. As a result, the kidneys are better able to filter and excrete excess fluid, leading to increased urine output. Therefore, an increase in urinary output indicates that the digoxin is having a positive effect in managing the client's congestive heart failure. The other options, such as increased weight, improved appetite, and increased pedal edema, are not indicative of a desired effect of digoxin therapy.

Correct Answer: D

Rationale: Postpartum hemorrhage is defined as a blood loss of more than 500 ml within the first 24 hours after vaginal delivery or more than 1000 ml following a cesarean delivery. Excessive bleeding can lead to hypovolemic shock and can be life-threatening if not promptly addressed. Therefore, a blood loss of more than 500 ml/24 hours would lead the nurse to suspect a postpartum hemorrhage and prompt further assessment and intervention.

Correct Answer: A

Rationale: The development of autoantibodies such as antinuclear antibodies (ANA) and anti-double-stranded DNA (anti-dsDNA) antibodies in systemic lupus erythematosus (SLE) is primarily attributed to a loss of self-tolerance. Self-tolerance refers to the immune system's ability to recognize and differentiate self-antigens from foreign antigens. In individuals with SLE, there is a breakdown in immune tolerance mechanisms, leading to the production of autoantibodies against self-antigens like nuclear components (e.g., DNA, RNA, histones). This loss of self-tolerance results in the immune system targeting and attacking its tissues, leading to the systemic inflammation and tissue damage characteristic of SLE. The presence of elevated levels of ANA and anti-dsDNA antibodies in this patient suggests an autoimmune response against nuclear material, further supporting the role of self-tolerance breakdown in SLE

Correct Answer: B

Rationale: When a woman in active labor is receiving intravenous oxytocin for labor augmentation, it is essential to increase the oxytocin infusion rate gradually to prevent oxytocin-induced uterine hyperstimulation. Uterine hyperstimulation can lead to complications such as fetal distress, uterine rupture, and postpartum hemorrhage. By increasing the oxytocin infusion rate gradually, the uterus has more time to adapt to the medication and reduces the risk of hyperstimulation. It is crucial for the healthcare provider to carefully monitor the woman's response to oxytocin and adjust the infusion rate as needed to ensure safe and effective labor augmentation. Monitoring for signs of uterine hyperstimulation, such as persistent contractions close together or excessive uterine activity, is crucial in preventing complications and ensuring the well-being of both the mother and baby.