Adult Health Nursing Test Banks

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A patient presents with progressive weakness, muscle atrophy, and fasciculations, primarily involving the upper and lower extremities. Over time, the patient develops dysphagia and dysarthria. Which of the following neurological conditions is most likely responsible for these symptoms?

  • A. Parkinson's disease
  • B. Guillain-Barré syndrome (GBS)
  • C. Amyotrophic lateral sclerosis (ALS)
  • D. Myasthenia gravis
Correct Answer: C

Rationale: The symptoms described, including progressive weakness, muscle atrophy, fasciculations, dysphagia, and dysarthria primarily involving the upper and lower extremities, are classic features of amyotrophic lateral sclerosis (ALS), also known as Lou Gehrig's disease. ALS is a progressive neurodegenerative disorder that affects the motor neurons in the brain and spinal cord, leading to muscle weakness and atrophy. As the disease progresses, patients may develop difficulty swallowing (dysphagia) and speaking (dysarthria). In contrast, Parkinson's disease primarily involves movement-related symptoms such as tremors, muscle stiffness, and slow movements. Guillain-Barré syndrome (GBS) is an acute inflammatory demyelinating polyneuropathy that typically presents with ascending weakness and sensory abnormalities, often preceded by an infection. Myasthenia gravis is characterized by muscle weakness exacerbated by

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During the normal postpartum course, when would the nurse expect to note the fundal assessment that will be in line with the umbilicus?

  • A. Immediately after the delivery
  • B. 4 days after the delivery
  • C. When the client's bladder is full
  • D. The day after the delivery
Correct Answer: D

Rationale: After childbirth, the uterus undergoes involution, which is the process of returning to its pre-pregnant size and location. Initially, the fundus is firm and located at or just below the level of the umbilicus immediately after delivery. Over the next 24 hours, the fundus should gradually decrease in height as involution progresses. By the day after delivery, the nurse would expect the fundal assessment to be in line with the umbilicus or slightly below it, indicating normal involution of the uterus. If the fundus remains high or deviates from this expected progression, further assessment and intervention may be needed to prevent complications such as postpartum hemorrhage.

Which of the following is an evidence of the a poor family coping Index related to healthcare attitudes ?

  • A. A parents who washes the wound of the child with running water
  • B. The family who observes the habit of cleaning surroundings.
  • C. A young mother who introduced solid food to her three-month-old baby.
  • D. A mother who brings her child to be vaccinated for measles,
Correct Answer: C

Rationale: Introducing solid food to a three-month-old baby is considered a poor healthcare attitude as it goes against the recommended guidelines for infant feeding. The World Health Organization (WHO) and other health authorities suggest exclusive breastfeeding for the first six months of a baby's life, followed by the introduction of safe and appropriate complementary foods. Introducing solid food too early can increase the risk of food allergies, obesity, and other health issues in babies. Therefore, a young mother introducing solid food to her three-month-old baby is evidence of a poor family coping index related to healthcare attitudes.

Which is the APPROPRIATE way to correct an error in the Nurses Notes?

  • A. Take the whole page out and replace with a fresh one
  • B. Draw a single 1ine across the error and initial it
  • C. Use the sticky side of the plastic tape to erase the error
  • D. Use a rubber eraser to erase an error.
Correct Answer: B

Rationale: The appropriate way to correct an error in the Nurses Notes is to draw a single line across the error and initial it. This method is recommended because it indicates that there was an error made, while still preserving the original information for audit and legal purposes. It shows transparency and accountability in documentation, as the original information remains visible. Taking the whole page out and replacing it with a fresh one can lead to discrepancies and potential legal issues if there are inconsistencies in the documentation. Using methods like using the sticky side of the plastic tape or a rubber eraser can make the documentation look unprofessional and raises questions about the accuracy and integrity of the notes.

A nurse is delegating tasks to a nursing assistant. What principle should guide the nurse's delegation decisions?

  • A. Delegating tasks according to the assistant's job description
  • B. Assigning tasks based on the assistant's level of experience
  • C. Delegating tasks that the nurse prefers not to perform
  • D. Providing tasks that are routine and do not require nursing judgment
Correct Answer: B

Rationale: When a nurse is delegating tasks to a nursing assistant, the principle that should guide the nurse's delegation decisions is assigning tasks based on the assistant's level of experience (Option B). It is essential to take into consideration the skills, competencies, and experience level of the nursing assistant to ensure that the tasks delegated are suitable for them to perform safely and effectively. Delegating tasks beyond the assistant's level of experience may result in errors, inefficiencies, or compromised patient care. Therefore, matching tasks with the assistant's experience level is crucial in successful delegation and providing quality patient care.

A patient with chronic respiratory failure secondary to severe restrictive lung disease requires long-term oxygen therapy to maintain adequate oxygenation. Which of the following oxygen delivery devices is most appropriate for delivering continuous supplemental oxygen in this patient?

  • A. Nasal cannula
  • B. Venturi mask
  • C. Partial rebreather mask
  • D. Non-rebreather mask
Correct Answer: D

Rationale: The most appropriate oxygen delivery device for a patient with chronic respiratory failure secondary to severe restrictive lung disease requiring continuous supplemental oxygen is a non-rebreather mask. A non-rebreather mask is designed to deliver high-flow oxygen and is typically used for short-term medical treatment in emergency situations or for critically ill patients. It is ideal for providing the highest concentration of oxygen available for inhalation, making it suitable for patients with severe hypoxemia.

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