Foundations and Adult Health Nursing Test Bank

Foundations and Adult Health Nursing Test Bank Related

Review Foundations and Adult Health Nursing Test Bank related questions and content

A patient is brought to the emergency department experiencing a possible stroke. What initial diagnostic test for a stroke , usually performed in the emergency department would the nurse prepare the patient for?

  • A. 12-lead electrocardiogram
  • B. Carotid ultrasound study
  • C. Noncontrast computed tomography
  • D. Transcranial Doppler flow study
Correct Answer: C

Rationale: In the emergency department setting, the initial diagnostic test typically performed for a patient suspected of having a stroke is a noncontrast computed tomography (CT) scan of the head. This imaging study is crucial in evaluating and diagnosing stroke because it can quickly identify whether the person is having a hemorrhagic stroke (bleeding in the brain) or an ischemic stroke (blood clot blocking a blood vessel). The results of the CT scan help guide immediate treatment decisions, such as administering clot-busting medications for ischemic strokes or preparing for surgical interventions for hemorrhagic strokes. Carotid ultrasound studies and transcranial Doppler flow studies may be performed after the initial CT scan to further assess the extent of damage and the underlying cause of the stroke. The 12-lead electrocardiogram is useful in assessing the heart's electrical activity but is not the primary test for diagnosing stroke.

You may also like to solve these questions

A patient with a history of cirrhosis is at risk for developing hepatic encephalopathy. Which nursing intervention is most effective in preventing and managing hepatic encephalopathy?

  • A. Administering lactulose as prescribed
  • B. Restricting dietary protein intake
  • C. Monitoring serum ammonia levels
  • D. Encouraging increased fluid intake
Correct Answer: A

Rationale: Lactulose is the most effective nursing intervention in preventing and managing hepatic encephalopathy in patients with cirrhosis. Lactulose works by promoting the elimination of ammonia in the colon through its laxative effect, thereby reducing ammonia levels in the blood. High ammonia levels are associated with the development of hepatic encephalopathy. By administering lactulose as prescribed, nurses can help reduce the risk of encephalopathy and manage symptoms effectively. Monitoring serum ammonia levels is important in assessing the effectiveness of lactulose therapy, but administering lactulose is the primary nursing intervention in this situation. Dietary protein restriction is also commonly recommended; however, lactulose administration is the most vital intervention in this scenario. Additionally, encouraging increased fluid intake is important for overall liver health but is not as specific to preventing and managing hepatic encephalopathy as administering lactulose.

A postpartum client exhibits signs of deep vein thrombosis (DVT), including calf pain, swelling, and warmth. Which nursing action is most appropriate?

  • A. Applying warm compresses to the affected calf
  • B. Encouraging ambulation to promote circulation
  • C. Notifying the healthcare provider immediately
  • D. Administering anticoagulant medication as ordered
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.

A patient presents with a pruritic rash with linear streaks and small, fluid-filled blisters. The patient reports recent exposure to poison ivy while gardening. Which of the following conditions is most likely responsible for this presentation?

  • A. Pemphigus vulgaris
  • B. Allergic contact dermatitis
  • C. Bullous pemphigoid
  • D. Herpes zoster (shingles)
Correct Answer: B

Rationale: The presentation of a pruritic rash with linear streaks and small, fluid-filled blisters following exposure to poison ivy is characteristic of allergic contact dermatitis. Poison ivy contains an oil called urushiol, which is known to cause this type of skin reaction in individuals who are sensitive to it. The linear streaks are often a result of the plant brushing against the skin. Pemphigus vulgaris is an autoimmune condition characterized by the formation of intraepidermal blisters, typically not associated with linear streaks or exposure to irritants like poison ivy. Bullous pemphigoid is characterized by subepidermal blisters, and herpes zoster presents with a painful rash following reactivation of the varicella-zoster virus in a dermatomal pattern, not typically in linear streaks.

The __________ is link between the nervous system and the endocrine system

  • A. Spinal cord
  • B. Pituitary gland
  • C. Hypothalamus
  • D. Thyroid gland
Correct Answer: C

Rationale: The hypothalamus is the link between the nervous system and the endocrine system. It plays a crucial role in maintaining homeostasis in the body by communicating with the pituitary gland, which is often referred to as the "master gland" of the endocrine system. The hypothalamus produces hormones that regulate the release of hormones from the pituitary gland, which then controls the functions of other endocrine glands throughout the body. This connection allows the nervous system to influence and coordinate various hormonal responses in the body, helping to regulate processes such as metabolism, growth, stress responses, and reproduction.

A client with congestive heart failure has been receiving digoxin (lanoxin). Which finding indicates that the medication is having a desired effect?

  • A. Increased weight
  • B. Increased urinary output
  • C. Improved appetite
  • D. Increased pedal edema
Correct Answer: B

Rationale: Digoxin is a medication commonly used in the treatment of congestive heart failure because it helps to improve cardiac output and reduce heart failure symptoms. One of the desired effects of digoxin is an increase in urinary output. This is because digoxin helps to improve cardiac function, which can lead to better circulation and increased kidney perfusion. As a result, the kidneys are better able to filter and excrete excess fluid, leading to increased urine output. Therefore, an increase in urinary output indicates that the digoxin is having a positive effect in managing the client's congestive heart failure. The other options, such as increased weight, improved appetite, and increased pedal edema, are not indicative of a desired effect of digoxin therapy.

Copyright © 2025 Nokea. All rights reserved.