Foundations and Adult Health Nursing Test Bank -Nurselytic

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: The theory of Nursing as Caring was developed by Dr. Jean Watson, a renowned nurse theorist and professor. Watson's Theory of Human Caring focuses on the importance of the nurse-patient relationship, emphasizing the significance of caring in promoting healing and promoting holistic well-being. This theory emphasizes the humanistic aspects of nursing care and highlights the nurse's role in fostering a caring environment that encompasses physical, emotional, social, and spiritual dimensions. Watson's theory emphasizes the importance of empathy, compassion, and authentic presence in nursing practice, making it a valuable framework for guiding nursing care and promoting healing outcomes.

Correct Answer: C

Rationale: When assessing and managing distress in a patient with advanced dementia who is no longer able to communicate verbally, the palliative nurse should consider exploring non-verbal cues and behaviors to identify the underlying causes of distress. Since the patient cannot communicate through words, it is essential to pay close attention to their non-verbal cues such as facial expressions, body language, and changes in behavior. Distress in dementia patients can be caused by a variety of factors including physical discomfort, unmet needs, environmental stressors, emotional distress, or even medication side effects. By carefully observing and interpreting non-verbal cues, the nurse can gain insight into what might be causing the patient's distress and tailor interventions accordingly. Simply focusing on physical comfort measures may not address the root cause of the distress, and administering sedative medications without understanding the underlying cause is not considered best practice in palliative care for dementia patients.

Correct Answer: A

Rationale: Troponin is the most specific cardiac biomarker for myocardial injury. Troponin I and Troponin T are proteins released into the bloodstream when there is damage to the heart muscle, making them highly indicative of myocardial infarction. Troponin levels rise within a few hours of cardiac injury, peak within 24-48 hours, and can remain elevated for up to 2 weeks. Troponin is considered the gold standard biomarker for the diagnosis of acute myocardial infarction due to its high specificity and sensitivity for cardiac injury. In contrast, Creatine kinase-MB (CK-M
B) and myoglobin are also used in diagnosing myocardial infarction but are less specific than troponin. Brain natriuretic peptide (BNP) is primarily used in heart failure diagnosis and management, and its levels are not specific to myocardial injury.

Correct Answer: A

Rationale: The first standard step in oxygen therapy that the nurse should do is to assess the client's condition. Before initiating any oxygen treatment, it is essential to assess the client's respiratory status, oxygen saturation levels, vital signs, and overall condition. This initial assessment helps the nurse to determine the appropriate course of oxygen therapy based on the client's individual needs and current health status. Assessing the client's condition first ensures that the oxygen therapy provided is safe and effective for the specific needs of the client.