Adult Health Nursing Test Bank

Adult Health Nursing Test Bank Related

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A patient presents with severe headache, photophobia, and neck stiffness. On examination, there is nuchal rigidity and positive Kernig and Brudzinski signs. Which of the following neurological conditions is most likely responsible for these symptoms?

  • A. Migraine headache
  • B. Cluster headache
  • C. Meningitis
  • D. Subarachnoid hemorrhage
Correct Answer: C

Rationale: The correct answer is C: Meningitis. The patient's symptoms of severe headache, photophobia, neck stiffness, nuchal rigidity, and positive Kernig and Brudzinski signs are classic signs of meningitis. Meningitis is an inflammation of the meninges surrounding the brain and spinal cord, leading to these specific neurological symptoms. Migraine headache (A) typically presents with a throbbing headache, nausea, and sensitivity to light and sound, but does not typically cause neck stiffness or positive meningeal signs. Cluster headache (B) is characterized by severe unilateral headache with autonomic symptoms like tearing or nasal congestion, but does not typically cause neck stiffness or positive meningeal signs. Subarachnoid hemorrhage (D) presents with sudden severe headache often described as "the worst headache of my life," and may cause neck stiffness, but typically does not present with photophobia or positive meningeal signs like Kernig and Brudzinski signs.

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Nurse Chona read in one nurse's notes chart this documentation: "Refused to eat and fell from bed". Which of the following is lacking in this documentation?

  • A. Time of complaint, for missed and reaction on fall incurred.
  • B. Referrals made on fall medications given and reasons of falling.
  • C. Contents or complaints, reasons of refusing meal and nature of fall.
  • D. Time of eating, medications for back pain and intense of pain.
Correct Answer: C

Rationale: The correct answer is C because the documentation lacks essential details regarding the contents of the complaints, reasons for refusing the meal, and the nature of the fall. This information is crucial for understanding the patient's condition and providing appropriate care. Choice A is not directly related to the documentation provided. Choice B is about referrals and medications, which are not mentioned in the documentation. Choice D is about eating time and medications for pain, which are also not relevant to the documentation provided. Therefore, the correct answer is C as it addresses the specific missing information in the nurse's notes.

A patient in the ICU develops acute exacerbation of chronic obstructive pulmonary disease (COPD) characterized by worsening dyspnea and increased sputum production. What intervention should the healthcare team prioritize to manage the patient's exacerbation?

  • A. Administer bronchodilator medications via nebulization for bronchodilation.
  • B. Initiate non-invasive positive pressure ventilation (NIPPV) for respiratory support.
  • C. Perform arterial blood gas analysis to assess oxygenation and ventilation.
  • D. Recommend chest physiotherapy to promote airway clearance.
Correct Answer: B

Rationale: The correct answer is B: Initiate non-invasive positive pressure ventilation (NIPPV) for respiratory support. In acute exacerbations of COPD, NIPPV helps improve ventilation and oxygenation, reducing the work of breathing and preventing the need for intubation. This intervention is a priority as it can rapidly stabilize the patient's respiratory status.

A: Administering bronchodilator medications is important in COPD management, but in severe exacerbations, NIPPV takes precedence.
C: Arterial blood gas analysis is important for assessing oxygenation and ventilation status, but it does not directly address the acute respiratory distress.
D: Chest physiotherapy can help with airway clearance in COPD, but in acute exacerbations, respiratory support with NIPPV is more urgent.

A Patients to take regularly Lithium after discharged. The MOST important information to impart to the patient and his family is that the patient should

  • A. not eat foods which has high tyramine content like cheese, wine, liver
  • B. limit his fluid intake
  • C. have a limited intake of sodium
  • D. have an adequate intake of sodium
Correct Answer: C

Rationale: The correct answer is C, to have a limited intake of sodium. Lithium can lead to increased sodium levels in the body, potentially causing toxicity. By limiting sodium intake, the patient can maintain a balance and prevent adverse effects. Choice A is incorrect as tyramine content is not directly related to lithium intake. Choice B is incorrect as fluid intake does not have a significant impact on lithium levels. Choice D is incorrect because an adequate intake of sodium can lead to worsening lithium toxicity.

When patient record reach the Medical Records, the assigned staff will _____.

  • A. store the charts in their respective shelves
  • B. separate the medico-legal charts
  • C. check the completeness of the charting of the doctors and nurses
  • D. bind the chart immediately
Correct Answer: C

Rationale: The correct answer is C because checking the completeness of the charting by doctors and nurses ensures that all necessary information is accurately documented, facilitating proper patient care and treatment. This step helps identify any missing or incorrect information that may impact patient safety.

A: Storing the charts in respective shelves is a routine task that does not involve verifying the accuracy or completeness of the information.
B: Separating medico-legal charts is important but does not directly address the completeness of charting by doctors and nurses.
D: Binding the charts immediately is not necessary before ensuring the completeness and accuracy of the information documented.

A patient presents with a painful, vesicular rash following a linear pattern on the left forearm. The patient reports a history of gardening without gloves. Which of the following conditions is most likely responsible for this presentation?

  • A. Allergic contact dermatitis
  • B. Herpes simplex virus infection
  • C. Scabies
  • D. Poison ivy dermatitis
Correct Answer: B

Rationale: The correct answer is B: Herpes simplex virus infection. The presentation of a painful, vesicular rash following a linear pattern on the left forearm is characteristic of herpes simplex virus infection, specifically herpes zoster (shingles). The linear pattern is due to the virus following a specific nerve pathway. This is different from the other choices - A: Allergic contact dermatitis typically presents as a diffuse rash at the site of contact with an allergen, not a linear pattern. C: Scabies presents with burrows and papules, not vesicles in a linear pattern. D: Poison ivy dermatitis causes a diffuse rash, not a linear vesicular rash.

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