Foundations and Adult Health Nursing Test Bank

Correct Answer: C

Rationale: It is not important for Myra to listen to the tape recordings only when she feels motivated or productive. In a nurse-patient interaction relationship, listening to tape recordings promptly (Choice A) is crucial because it ensures that any important information or cues are not missed or forgotten. Additionally, noting voice tone and inflection (Choice B) and observing pauses (Choice D) are essential for understanding the nuances and emotions conveyed during the interaction, which can be crucial in effective communication. Listening based on motivation may lead to delays and hamper the timely analysis and understanding of the interactions. Hence, it is important for Myra to prioritize active and focused listening to the tape recordings, regardless of her current motivation levels.

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: Adenomyosis is a condition characterized by the presence of endometrial tissue within the myometrium (muscle wall) of the uterus. It can present with symptoms such as cyclic pelvic pain, dysmenorrhea (painful periods), and infertility. On pelvic examination, the uterus may be retroverted (tilted backward) and enlarged due to the presence of adenomyotic nodules within the uterine muscle. Adenomyosis can also cause heavy menstrual bleeding (menorrhagia). Endometriosis, on the other hand, involves the presence of endometrial tissue outside the uterus and can cause similar symptoms but is less likely to result in uterine enlargement or retroversion. Leiomyomas (uterine fibroids) are benign tumors of the uterine muscle and can also cause pelvic pain and abnormal uterine enlargement but are less likely to be associated with dysmenorrhea and infertility

Correct Answer: C

Rationale: When assessing and managing distress in a patient with advanced dementia who is no longer able to communicate verbally, the palliative nurse should consider exploring non-verbal cues and behaviors to identify the underlying causes of distress. Since the patient cannot communicate through words, it is essential to pay close attention to their non-verbal cues such as facial expressions, body language, and changes in behavior. Distress in dementia patients can be caused by a variety of factors including physical discomfort, unmet needs, environmental stressors, emotional distress, or even medication side effects. By carefully observing and interpreting non-verbal cues, the nurse can gain insight into what might be causing the patient's distress and tailor interventions accordingly. Simply focusing on physical comfort measures may not address the root cause of the distress, and administering sedative medications without understanding the underlying cause is not considered best practice in palliative care for dementia patients.

Correct Answer: C

Rationale: A simple hysterectomy involves the removal of the uterus and cervix. It does not involve the removal of the fallopian tubes or ovaries. In some cases, the fallopian tubes may be removed along with the uterus, but this would be specified as a different type of hysterectomy (such as a total hysterectomy or a radical hysterectomy). The removal of the ovaries, if necessary, would be indicated as an oophorectomy.