Adult Health Nursing Test Bank

Correct Answer: C

Rationale: The correct answer is C: Abrasion. Abrasion is the wearing away of tooth structure due to friction from external sources like toothbrushing or abrasive toothpaste. Dental caries (A) refers to tooth decay caused by bacteria. Attrition (B) is the wearing down of tooth structure due to tooth-to-tooth contact. Erosion (D) is the loss of tooth structure from acid attacks, not friction. Therefore, option C is the most fitting choice based on the description given.

Correct Answer: A

Rationale: The correct answer is A: Bleeding. Chemotherapy can lead to low platelet counts (thrombocytopenia), increasing the risk of bleeding. The priority goal of the nurse is to prevent bleeding by taking precautions such as avoiding invasive procedures, using soft toothbrushes, and monitoring for signs of bleeding. Infection (B) is important but not the priority as bleeding can be life-threatening. Hypotension (C) is not directly related to thrombocytopenia. Diarrhea (D) is a potential side effect of chemotherapy but is not the priority when considering thrombocytopenia.

Correct Answer: C

Rationale: The correct answer is C: unfreezing. Unfreezing is the initial stage in Lewin's planned change model where individuals become open to change by recognizing the need for it. During this stage, the nurse identifies the need for change, plans strategies to implement it, and works on overcoming resistance by ensuring that the driving forces (reasons for change) outweigh the restraining forces (barriers to change). Refreezing (A) is the final stage where the changes are reinforced and integrated into the organization. Movement (B) is the stage where actual change occurs, and in activism (D) is not a recognized stage in Lewin's model.

Correct Answer: D

Rationale: The correct answer is D because confirming the insertion site and direction using imaging guidance ensures precise placement of the chest tube, minimizing the risk of complications. Imaging guidance allows the nurse to visualize the exact location of the pneumothorax and guide the tube insertion accurately. A: Positioning the patient in a semi-Fowler's position with arms elevated may be beneficial for comfort but does not directly ensure proper chest tube placement. B: Marking the insertion site with a pen may help as a reference point but does not guarantee accurate placement. C: Administering analgesia is important for the patient's comfort but does not impact the placement of the chest tube. In summary, choice D is the most critical step to ensure the chest tube is correctly placed and effectively treats the pneumothorax.

Correct Answer: C

Rationale: The correct answer is C: Hyponatremia. SSRI medications can lead to the syndrome of inappropriate antidiuretic hormone secretion (SIADH), causing hyponatremia. This occurs due to increased levels of serotonin affecting the hypothalamus, leading to excessive ADH release. Hyponatremia can result in neurological symptoms and must be closely monitored. A: Bradycardia is not a common adverse effect of SSRIs. B: Hyperkalemia is not typically associated with SSRIs. D: Hypertension is not a common adverse effect of SSRIs; they may actually lower blood pressure.