Foundations and Adult Health Nursing Test Bank

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.

Correct Answer: A

Rationale: Endometriosis is a condition characterized by the abnormal growth of endometrial tissue outside the uterus. One common symptom of endometriosis is excessive menstrual bleeding, known as menorrhagia. This excessive bleeding is due to the presence of endometrial tissue in abnormal locations, leading to inflammation, scarring, and blood accumulation. In severe cases, endometriosis can lead to the formation of adhesions, cysts, and scar tissue, causing significant pain and fertility issues for affected individuals. Endometrial hyperplasia, leiomyomas (uterine fibroids), and adenomyosis are other gynecological conditions, but they do not involve the abnormal proliferation of endometrial tissue outside the uterus like endometriosis does.

Correct Answer: C

Rationale: The analytic approach refers to a method that views factors that influence health and by which interventions to improve health are directed. In this case, utilizing an analytic approach in the research means looking into the root causes of the health problems in the community, analyzing various factors that contribute to the prevalence of obesity and heart ailments, and developing targeted interventions to address these issues effectively. This approach involves identifying underlying reasons for health problems and strategically planning interventions to improve the health outcomes of the community.

Correct Answer: B

Rationale: When a patient with chronic kidney disease is prescribed erythropoietin-stimulating agents (ESAs) for anemia management, the parameter that should be monitored closely by the nurse is the hemoglobin levels. Hemoglobin levels indicate the patient's response to ESA therapy and are essential in assessing the effectiveness of the treatment in addressing anemia. Monitoring hemoglobin levels helps ensure that the patient's anemia is controlled within the target range to avoid both the risks of under-treatment (resulting in persistent anemia) and over-treatment (increased risk of adverse outcomes such as hypertension, stroke, or cardiovascular events).

Correct Answer: A

Rationale: Attention deficit hyperactivity disorder (ADHD) is characterized by inattentiveness, overactivity, and impulsiveness. Individuals with ADHD may have difficulty paying attention, completing tasks, sitting still, or controlling their impulses. Mental retardation (now referred to as intellectual disability) is a separate condition characterized by limitations in intellectual functioning and adaptive behaviors. While individuals with ADHD may experience difficulties in school or work due to their symptoms, ADHD itself does not indicate mental retardation.