Adult Health Nursing Test Bank

Adult Health Nursing Test Bank Related

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A patient receiving palliative care for end-stage cancer experiences intractable pain despite receiving opioid medications. What intervention should the palliative nurse prioritize to address the patient's pain?

  • A. Increase the dosage of the current opioid medication.
  • B. Switch to a different opioid medication with a different potency.
  • C. Administer adjuvant analgesic medications to enhance pain relief.
  • D. Refer the patient to a pain management specialist for evaluation.
Correct Answer: D

Rationale: The correct answer is D because referring the patient to a pain management specialist for evaluation is essential in this scenario. The specialist can conduct a comprehensive assessment to identify the underlying causes of the intractable pain and recommend a tailored pain management plan. This approach ensures a multidisciplinary approach to address the complex nature of the patient's pain.

Choice A is incorrect because simply increasing the dosage of the current opioid medication may not effectively address the underlying cause of the pain and can lead to potential side effects or opioid tolerance.

Choice B is incorrect as switching to a different opioid medication without a thorough evaluation may not guarantee better pain control and can increase the risk of adverse effects or inadequate pain relief.

Choice C is incorrect as administering adjuvant analgesic medications without addressing the root cause of the pain may not provide adequate pain relief and does not address the need for a specialized pain management plan.

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Annie states,'I 'm afraid to 1et my children out of my sight now that I can't hear them." What is the nurse ' s BEST response?

  • A. Tell me about your fears of losing contact with your children now that you can't hear them.
  • B. Children need some freedom, and the mother has to learn trust them. "
  • C. Do the children usually misbehave when they cannot be seen or heard by you?"
  • D. "What can the children do to make you feel more comfortable?
Correct Answer: A

Rationale: Rationale:
A is the correct answer as it demonstrates therapeutic communication by encouraging Annie to express her feelings and fears. It shows empathy and understanding, allowing Annie to elaborate on her concerns. B is incorrect as it dismisses Annie's fears and implies blame on her parenting. C is incorrect as it focuses on the behavior of the children rather than addressing Annie's emotions. D is incorrect as it places the responsibility on the children to make Annie feel comfortable, rather than addressing her concerns directly.

Which of the following situation is an example of incongruent message?

  • A. When the nurse means what she says
  • B. When the words and behavior of the nurse agree
  • C. When what the nurse says and does do not agree
  • D. When content and process agree
Correct Answer: C

Rationale: Step 1: Incongruent message occurs when verbal and nonverbal communication do not align.
Step 2: Choice C states "When what the nurse says and does do not agree," indicating a lack of alignment.
Step 3: This inconsistency can lead to confusion or mistrust in communication.
Step 4: Choices A, B, and D all describe situations with alignment between words and actions, making them congruent.
Summary: Choice C is correct as it exemplifies incongruent communication, while Choices A, B, and D are incorrect as they describe congruent messages.

A patient presents with sudden-onset, painless vision loss in the right eye. Fundoscopic examination reveals a cherry-red spot at the macula and attenuated retinal vessels. Which of the following conditions is most likely responsible for this presentation?

  • A. Central retinal artery occlusion
  • B. Central retinal vein occlusion
  • C. Retinal detachment
  • D. Acute angle-closure glaucoma
Correct Answer: A

Rationale: The correct answer is A: Central retinal artery occlusion. This condition presents with sudden-onset, painless vision loss, cherry-red spot at the macula due to lack of blood flow, and attenuated retinal vessels. The cherry-red spot is due to the transparency of the fovea when there is ischemia in the surrounding retina. Central retinal vein occlusion (B) presents with sudden vision loss accompanied by retinal hemorrhages and dilated tortuous veins. Retinal detachment (C) typically presents with sudden flashes, floaters, and a curtain-like visual field defect. Acute angle-closure glaucoma (D) presents with severe eye pain, blurred vision, halos around lights, and a fixed mid-dilated pupil.

Which of the following would prove that the nursing action carried out met, the standards of care on falls ?

  • A. Utilizing the nursing process in providing safe, quality nursing care
  • B. Documenting the procedures done
  • C. Carrying out the doctor's order
  • D. Performing physical assessment
Correct Answer: A

Rationale: The correct answer is A: Utilizing the nursing process in providing safe, quality nursing care. This is because the nursing process involves assessment, diagnosis, planning, implementation, and evaluation, which ensures comprehensive and individualized care. Documenting procedures (B) is important but does not guarantee meeting standards of care. Simply carrying out doctor's orders (C) may not address all aspects of patient care. Performing physical assessment (D) is crucial but only one component of the nursing process. Ultimately, utilizing the nursing process ensures holistic and evidence-based care, meeting the standards of care on falls.

A patient with a suspected autoimmune disorder exhibits antibodies directed against self-antigens, leading to tissue damage and inflammation. Which of the following mechanisms is primarily responsible for the development of autoimmune diseases?

  • A. Loss of self-tolerance
  • B. Failure of innate immunity
  • C. Defective T cell activation
  • D. Impaired phagocytosis
Correct Answer: A

Rationale: The correct answer is A: Loss of self-tolerance. This is because autoimmune diseases result from a breakdown in the immune system's ability to distinguish between self and non-self antigens, leading to the production of antibodies against self-antigens. When self-tolerance is lost, immune cells mistakenly target the body's own tissues, causing tissue damage and inflammation.

Choice B (Failure of innate immunity) is incorrect because autoimmune diseases are primarily driven by adaptive immunity rather than innate immunity. Choice C (Defective T cell activation) is incorrect as T cells play a critical role in the immune response to self-antigens in autoimmune diseases. Choice D (Impaired phagocytosis) is incorrect as phagocytosis is a mechanism primarily involved in the removal of pathogens, not in the development of autoimmune diseases.

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