Adult Health Nursing Test Banks

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A patient in the ICU develops acute gastrointestinal bleeding (GIB) requiring urgent intervention. What intervention should the healthcare team prioritize to manage the patient's bleeding?

  • A. Perform endoscopic hemostasis with mechanical or thermal techniques.
  • B. Administer proton pump inhibitors (PPIs) to reduce gastric acid secretion.
  • C. Implement strict bed rest to minimize physical exertion and bleeding risk.
  • D. Recommend transfusion of fresh frozen plasma to correct coagulopathy.
Correct Answer: A

Rationale: The healthcare team should prioritize performing endoscopic hemostasis with mechanical or thermal techniques in a patient with acute gastrointestinal bleeding (GIB) requiring urgent intervention. This approach involves directly visualizing the bleeding site and applying methods such as clipping, coagulation, or band ligation to stop the bleeding. Endoscopic hemostasis is considered the gold standard for managing acute GIB as it allows for both diagnostic and therapeutic intervention in real-time, offering a targeted and effective way to control bleeding and prevent recurrent episodes. Administering proton pump inhibitors (PPIs) may help in reducing gastric acid secretion and promoting ulcer healing but is not the primary intervention for actively bleeding patients. Implementing strict bed rest may be necessary in some cases to minimize physical exertion, but it is not the primary intervention to manage acute GIB. Transfusion of fresh frozen plasma to correct coagulopathy may be necessary if

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A rape victim tells the emergency nurse, I feel so dirty. Help me take a shower before I get examined. The nurse should:

  • A. arrange for the victim to shower.
  • B. give the victim a basin of water and towels.
  • C. offer the victim a shower after evidence is collected .
  • D. explain that bathing facilities are not available in the emergency department.
Correct Answer: C

Rationale: The correct response for the nurse in this situation would be to offer the victim a shower after evidence is collected. It is essential to preserve any physical evidence that may be present from the assault during the forensic examination. Allowing the victim to shower before evidence is collected could potentially compromise the evidence and hinder the investigation. The nurse should provide support to the victim during this difficult time and assure them that they will have the opportunity to shower once the necessary evidence is obtained. It is also crucial for the nurse to offer empathy and understanding while explaining the importance of preserving any evidence related to the assault.

After a throurough assessment by the physician-specialist, an order for an immediate sonogram was made specific for the medical condition?

  • A. Operation Room
  • B. Intervention
  • C. Laboratory
  • D. CT Scan
Correct Answer: B

Rationale: In this scenario, the physician-specialist assessed the patient and determined that an immediate sonogram is needed for the medical condition. An intervention is a specific action taken in response to a medical need or condition. Ordering an immediate sonogram falls under the category of an intervention because it involves a timely and targeted diagnostic procedure to address the medical situation identified by the physician. The other options (A. Operation Room, C. Laboratory, D. CT scan) do not accurately represent the specific action of ordering a sonogram in response to the medical condition assessed by the physician.

A woman in active labor experiences prolonged and severe pain in the lower back region, along with irregular contractions. What maternal condition should the nurse consider as a potential cause of abnormal labor progress?

  • A. Occiput posterior fetal position
  • B. Uterine hyperstimulation
  • C. Maternal exhaustion
  • D. Intrauterine infection
Correct Answer: A

Rationale: An occiput posterior fetal position, where the baby's head is facing the mother's abdomen rather than her back, can lead to prolonged and severe back pain during labor. This position can cause irregular contractions and difficulty in descending through the birth canal, resulting in abnormal labor progress. The back pain experienced in this case is often intense due to the pressure exerted on the mother's lower back and may also be associated with intense back labor. It is essential for the nurse to recognize this potential issue and assist in maneuvers or positions to help the baby rotate to a more optimal position for delivery.

Which of the following conditions is characterized by an imbalance between bone resorption and formation, resulting in bone thinning and increased risk of fractures?

  • A. Osteoarthritis
  • B. Osteomyelitis
  • C. Osteoporosis
  • D. Osteomalacia
Correct Answer: C

Rationale: Osteoporosis is a condition characterized by an imbalance between bone resorption (breakdown of bone tissue) and bone formation, leading to bone thinning and increased risk of fractures. In osteoporosis, bones become weak and porous, making them more prone to fractures even with minor trauma. This condition is common in postmenopausal women and older individuals. Risk factors for osteoporosis include age, gender, family history, lack of physical activity, low calcium and vitamin D intake, smoking, excessive alcohol consumption, and certain medications. Treatment typically involves lifestyle modifications, including adequate calcium and vitamin D intake, weight-bearing exercises, and sometimes medication to help slow down bone loss and reduce fracture risk. Early detection and management of osteoporosis are crucial to prevent fractures and maintain bone health.

Which of the following is a common complication associated with Dupuytren's contracture?

  • A. Trigger finger
  • B. Swan-neck deformity
  • C. Boutonniere deformity
  • D. Mallet finger
Correct Answer: B

Rationale: Dupuytren's contracture is a condition characterized by the thickening and tightening of the tissue beneath the skin of the hand, leading to the fingers being pulled into a bent position. One of the common complications associated with Dupuytren's contracture is the development of a Swan-neck deformity. This deformity is characterized by hyperextension of the proximal interphalangeal joint and flexion of the distal interphalangeal joint. It is important to recognize and address complications like Swan-neck deformity in individuals with Dupuytren's contracture to prevent further functional impairment and disability.

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