Foundations and Adult Health Nursing Test Bank

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A patient presents with sudden-onset severe headache, vomiting, and altered mental status. Imaging reveals a berry-shaped aneurysm at the junction of the anterior communicating artery and anterior cerebral artery. Which of the following neurological conditions is most likely responsible for these symptoms?

  • A. Ischemic stroke
  • B. Intracerebral hemorrhage
  • C. Subdural hematoma
  • D. Subarachnoid hemorrhage
Correct Answer: D

Rationale: The presentation of sudden-onset severe headache, vomiting, and altered mental status, along with the presence of a berry-shaped aneurysm on imaging, point towards a diagnosis of subarachnoid hemorrhage. The most common cause of a subarachnoid hemorrhage is the rupture of a saccular (berry) aneurysm, which commonly occurs at the junction of the anterior communicating artery and anterior cerebral artery. The sudden headache is often described as the "worst headache of my life" and is typically associated with nausea and vomiting. Altered mental status may be present due to the effects of increased intracranial pressure and possible associated brain injury. It is important to promptly diagnose and manage subarachnoid hemorrhage to prevent complications such as vasospasm, rebleeding, and ischemic deficits.

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A patient with heart failure is prescribed digoxin. Which electrolyte imbalance increases the risk of digoxin toxicity?

  • A. Hyperkalemia
  • B. Hypernatremia
  • C. Hypokalemia
  • D. Hyponatremia
Correct Answer: C

Rationale: Hypokalemia (low levels of potassium) increases the risk of digoxin toxicity. This is because digoxin competes with potassium for binding sites on the sodium-potassium ATPase pump in the cell membrane. When potassium levels are low, there is an increased binding of digoxin to these pumps, leading to enhanced entry of calcium into the cells. This can result in an increased intracellular calcium concentration, leading to digoxin toxicity and potential cardiac arrhythmias. Therefore, monitoring and correcting potassium levels is crucial in patients prescribed digoxin to reduce the risk of toxicity.

Nurse Adalynn explains to the mothers that early indication for hypovolemia caused by postpartum hemorrhage is _____.

  • A. increasing pulse and decreasing blood pressure
  • B. altered mental status and level of consciousness
  • C. dizziness and increasing respiratory rate
  • D. Cool, clammy skin, and pale mucous membranes
Correct Answer: A

Rationale: Nurse Adalynn explains to the mothers that early indication for hypovolemia caused by postpartum hemorrhage is an increasing pulse and decreasing blood pressure. Hypovolemia is a condition where there is a decreased volume of circulating blood in the body, often characterized by fluid loss such as through bleeding. As blood volume decreases, the heart rate increases in an attempt to maintain adequate perfusion to organs and tissues. This results in an elevated pulse rate. Additionally, as the blood volume decreases, the blood pressure may drop due to the reduced amount of blood being pumped around the body. Therefore, monitoring for an increasing pulse and decreasing blood pressure is crucial in detecting hypovolemia early, allowing for prompt intervention to prevent further complications.

The incoming nurse on duty reported, the nurse is administering a medication, the patient says, "This pill looks different from the one I had taken before. " What is the APPROPRIATE action of the nurse?

  • A. Explain the purpose of the medication.
  • B. Encourage the patient to take the medication.
  • C. Check the original medication pre scription.
  • D. Ask what the other pill looked 1ike.
Correct Answer: C

Rationale: When a patient expresses concern about a medication looking different from what they had taken before, it is crucial for the nurse to verify the original prescription to ensure that the correct medication is being administered. Checking the original medication prescription will help the nurse confirm if there have been any changes or errors in the medication orders. This step is essential for patient safety and to prevent any potential medication errors. It is important to prioritize patient safety and well-being in such situations, and verifying the prescription is the appropriate action to take in this case.

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.

You have observed presence of drainage in Claudia's eyes. Which of the following eye solution would you use in cleaning her eyes?

  • A. Hydrochloric acid
  • B. Mineral water
  • C. Normal saline solution
  • D. Soapsuds solution
Correct Answer: C

Rationale: Normal saline solution is the best choice for cleaning Claudia's eyes with drainage. It is a sterile solution that closely matches the natural pH of the eyes, making it gentle and safe for ocular use. Normal saline can help flush out any debris or discharge in the eye without causing further irritation or complications. On the other hand, hydrochloric acid is a corrosive substance that can cause significant harm if it comes into contact with the eyes. Mineral water may contain impurities that could further irritate the eyes. Soapsuds solution is not recommended for eye cleaning as it can cause irritation and damage to the delicate eye tissues. Therefore, normal saline solution is the most appropriate and safe option for cleaning Claudia's eyes in this situation.

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