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: C

Rationale: In the case of Mang Luis, who has been diagnosed with chronic obstructive pulmonary disease (COPD) and is experiencing exacerbation, the most crucial health intervention to include in the teaching plan is to reduce the risk for infection. COPD exacerbations are commonly triggered by respiratory infections such as pneumonia and bronchitis. Preventing infections is essential in managing COPD as they can lead to worsening of symptoms and increased healthcare utilization. Therefore, educating Mang Luis on strategies to reduce the risk of infection, such as proper hand hygiene, avoiding exposure to sick individuals, getting vaccinated, and managing environmental factors, is paramount in his care plan.

Correct Answer: D

Rationale: Advocacy is the ethical principle that the nurse is responsible for providing all patients with caring attention and information, despite the reaction of the patient. Advocacy involves supporting and speaking up for the patient's best interests, ensuring they receive the care and information they need to make informed decisions about their health and well-being. Providing caring attention and information is essential in advocating for the patient's autonomy and well-being, even if the patient may not initially appreciate or react positively to these efforts.

Correct Answer: A

Rationale: The development of autoantibodies such as antinuclear antibodies (ANA) and anti-double-stranded DNA (anti-dsDNA) antibodies in systemic lupus erythematosus (SLE) is primarily attributed to a loss of self-tolerance. Self-tolerance refers to the immune system's ability to recognize and differentiate self-antigens from foreign antigens. In individuals with SLE, there is a breakdown in immune tolerance mechanisms, leading to the production of autoantibodies against self-antigens like nuclear components (e.g., DNA, RNA, histones). This loss of self-tolerance results in the immune system targeting and attacking its tissues, leading to the systemic inflammation and tissue damage characteristic of SLE. The presence of elevated levels of ANA and anti-dsDNA antibodies in this patient suggests an autoimmune response against nuclear material, further supporting the role of self-tolerance breakdown in SLE

Correct Answer: C

Rationale: NSAIDs are known to increase the risk of gastrointestinal complications, particularly gastrointestinal bleeding, ulcers, and perforation. This risk is higher in patients who are elderly, have a history of peptic ulcer disease, are taking high doses of NSAIDs, or are using them for a prolonged period. It is important for the nurse to closely monitor the patient for signs and symptoms of gastrointestinal bleeding, such as abdominal pain, black or tarry stools, vomiting blood, and anemia. Prompt identification and management of these complications are essential to prevent serious consequences. Monitoring for gastrointestinal adverse effects is crucial when a patient is prescribed NSAIDs for managing conditions like osteoarthritis.