Foundations and Adult Health Nursing Test Bank

Correct Answer: C

Rationale: Fowler's position is the correct position to help a patient experiencing breathing difficulty. In Fowler's position, the patient is sitting up at a 45- to 60-degree angle with the legs either straight or bent. This position allows for maximum chest expansion, helping to improve ventilation and oxygenation. It is commonly used to assist patients with respiratory distress, including difficulties with breathing. Placing the patient in Fowler's position can alleviate the feeling of breathlessness and facilitate easier breathing by promoting better lung expansion.

Correct Answer: A

Rationale: Lactulose is the most effective nursing intervention in preventing and managing hepatic encephalopathy in patients with cirrhosis. Lactulose works by promoting the elimination of ammonia in the colon through its laxative effect, thereby reducing ammonia levels in the blood. High ammonia levels are associated with the development of hepatic encephalopathy. By administering lactulose as prescribed, nurses can help reduce the risk of encephalopathy and manage symptoms effectively. Monitoring serum ammonia levels is important in assessing the effectiveness of lactulose therapy, but administering lactulose is the primary nursing intervention in this situation. Dietary protein restriction is also commonly recommended; however, lactulose administration is the most vital intervention in this scenario. Additionally, encouraging increased fluid intake is important for overall liver health but is not as specific to preventing and managing hepatic encephalopathy as administering lactulose.

Correct Answer: B

Rationale: The presentation of a pruritic rash with linear streaks and small, fluid-filled blisters following exposure to poison ivy is characteristic of allergic contact dermatitis. Poison ivy contains an oil called urushiol, which is known to cause this type of skin reaction in individuals who are sensitive to it. The linear streaks are often a result of the plant brushing against the skin. Pemphigus vulgaris is an autoimmune condition characterized by the formation of intraepidermal blisters, typically not associated with linear streaks or exposure to irritants like poison ivy. Bullous pemphigoid is characterized by subepidermal blisters, and herpes zoster presents with a painful rash following reactivation of the varicella-zoster virus in a dermatomal pattern, not typically in linear streaks.

Correct Answer: C

Rationale: A Likert Scale is typically used to measure the degree of agreement or disagreement with a set of statements or questions. Respondents are asked to indicate their level of agreement or disagreement using a scale that ranges from, for example, "strongly agree" to "strongly disagree". This makes it a suitable tool for assessing the degree of agreement and disagreement among individuals on various topics or statements. While a Likert Scale can potentially measure other constructs such as satisfaction or acceptance, its primary purpose and most common application involve determining the degree of agreement and disagreement.

Correct Answer: B

Rationale: The patient who had a left total hip replacement surgery due to osteoarthritis needs to strictly follow the postoperative teaching of being shown how to gently irrigate the external auditory canal because this instruction is unrelated to a hip replacement surgery. The other options are not relevant to the surgery and patient's condition. Option A about airplane travel, Option C about dizziness, and Option D about hair washing are not appropriate instructions for a patient who had a hip replacement. It is important for healthcare providers to give accurate and relevant postoperative instructions to help the patient recover successfully.