Foundations and Adult Health Nursing Test Bank

Correct Answer: A

Rationale: Ambivalence is the most common emotional response among women during the first trimester of pregnancy. This is because the news of being pregnant might evoke a mix of emotions, including joy and apprehension. Women may feel uncertain about their readiness for the responsibility of motherhood, have concerns about changes in their body, or worry about the impact on their career or relationships. Ambivalence is a natural response to a significant life change, and many women experience conflicting feelings before fully accepting and embracing their pregnancy.

Correct Answer: D

Rationale: Addison's disease is a rare endocrine disorder characterized by adrenal insufficiency, leading to a deficiency in cortisol and aldosterone production. The symptoms of Addison's disease include fatigue, weakness, hyperpigmentation of the skin (due to elevated levels of ACTH stimulating melanocytes), and salt craving (due to aldosterone deficiency). Low serum sodium levels and elevated serum potassium levels are also common laboratory findings in Addison's disease, as aldosterone plays a key role in maintaining electrolyte balance. Patients with Addison's disease are at risk of developing an adrenal crisis, which can be life-threatening if not promptly recognized and treated with glucocorticoid and mineralocorticoid replacement therapy.

Correct Answer: D

Rationale: Demerol (meperidine hydrochloride) is an opioid analgesic commonly used as a preoperative medication to decrease intra-operative anesthetic requirements and provide analgesia. Opioids like Demerol act on the central nervous system to reduce pain sensations, making it an effective choice for preoperative pain management. This can help decrease the amount of anesthesia needed during surgery, leading to better pain control and overall patient comfort during and after the procedure. Celebrex, acetaminophen, and ibuprofen are also used for pain management, but they do not have the same potency and mechanism of action as opioids like Demerol for reducing intra-operative anesthetic requirements.

Correct Answer: C

Rationale: Deep vein thrombosis (DVT) is a serious condition that requires prompt medical intervention. The presence of calf pain, swelling, and warmth in a postpartum client are concerning signs of a potential DVT. By notifying the healthcare provider immediately, appropriate diagnostic tests, such as ultrasound imaging, can be ordered to confirm the diagnosis. Timely treatment with anticoagulant medication can then be initiated to prevent complications such as pulmonary embolism. Applying warm compresses or encouraging ambulation may exacerbate the condition by promoting clot dislodgement, making immediate notification of the healthcare provider the most appropriate nursing action in this situation.

Correct Answer: C

Rationale: The nurse should reposition the patient to alleviate pressure on vulnerable areas. Pressure injuries can develop when there is prolonged pressure on specific areas of the skin, leading to reduced blood flow and tissue damage. Repositioning the patient helps to relieve the pressure and prevent the development of pressure injuries. Applying a pressure-relieving device may also be helpful, but the immediate action should be to reposition the patient to address the issue. Documenting the observation is important for documentation purposes, but the priority is to take action to prevent harm to the patient. Continuing with the positioning as planned without addressing the inadequate skin protection could lead to the development of pressure injuries, which should be avoided.