Adult Health Nursing Test Banks

Correct Answer: C

Rationale: Introducing solid food to a three-month-old baby is considered a poor healthcare attitude as it goes against the recommended guidelines for infant feeding. The World Health Organization (WHO) and other health authorities suggest exclusive breastfeeding for the first six months of a baby's life, followed by the introduction of safe and appropriate complementary foods. Introducing solid food too early can increase the risk of food allergies, obesity, and other health issues in babies. Therefore, a young mother introducing solid food to her three-month-old baby is evidence of a poor family coping index related to healthcare attitudes.

Correct Answer: D

Rationale: After childbirth, the uterus undergoes involution, which is the process of returning to its pre-pregnant size and location. Initially, the fundus is firm and located at or just below the level of the umbilicus immediately after delivery. Over the next 24 hours, the fundus should gradually decrease in height as involution progresses. By the day after delivery, the nurse would expect the fundal assessment to be in line with the umbilicus or slightly below it, indicating normal involution of the uterus. If the fundus remains high or deviates from this expected progression, further assessment and intervention may be needed to prevent complications such as postpartum hemorrhage.

Correct Answer: D

Rationale: Upon clinical assessment, the nurse observes that the outstanding manifestation of the patient is edema. Edema is characterized by the accumulation of excess fluid in the body's tissues, leading to swelling. Edema can be a sign of various health conditions, such as heart failure, kidney disease, liver disease, or injury. It is crucial to identify and address the underlying cause of edema promptly to prevent complications and provide appropriate treatment for the patient.

Correct Answer: B

Rationale: Vitamin K is essential for the production of several clotting factors in the liver, including factors II, VII, IX, and X. In a patient with chronic liver disease, impaired liver function can lead to decreased synthesis of these clotting factors. As a result, there is an underlying deficiency of these clotting factors, leading to prolonged PT (prothrombin time) and aPTT (activated partial thromboplastin time). The mixing studies showing correction with normal plasma further support the diagnosis of a factor deficiency rather than an inhibitor, which helps in ruling out conditions like DIC or hemophilia.

Correct Answer: A

Rationale: The primary intervention that should be prioritized for managing a catheter-related bloodstream infection (CRBSI) associated with a central venous catheter is to remove the central venous catheter. CRBSI is a serious complication that can lead to severe infections and sepsis. The removal of the catheter is crucial to eliminate the source of the infection and prevent further dissemination of the pathogens into the bloodstream. Once the catheter is removed, the healthcare team can consider other interventions such as administering targeted antibiotics based on culture results, performing blood cultures to identify the causative organism, and implementing sterile dressing changes and catheter care protocols. However, immediate removal of the catheter takes precedence in managing CRBSI to prevent worsening of the infection and improve patient outcomes.