Adult Health Nursing Test Banks

Adult Health Nursing Test Banks Related

Review Adult Health Nursing Test Banks related questions and content

A postpartum client who is breastfeeding expresses concerns about breast engorgement and discomfort. What nursing intervention should be prioritized to alleviate symptoms?

  • A. Encouraging frequent breastfeeding or pumping sessions
  • B. Applying cold packs to the breasts between feedings
  • C. Recommending the use of a supportive bra or breast binder
  • D. Administering oral analgesics for pain relief
Correct Answer: A

Rationale: The most appropriate nursing intervention to alleviate breast engorgement and discomfort in a breastfeeding client is to encourage frequent breastfeeding or pumping sessions. Engorgement occurs when the breasts become overly full of milk, causing them to become swollen, firm, and painful. By ensuring that the baby breastfeeds frequently, the client can effectively empty the breasts, which helps to relieve engorgement and discomfort. Encouraging the client to breastfeed on demand and ensuring proper latching can help prevent further engorgement issues. Pumping can also be useful if the baby is unable to feed directly from the breast or to relieve engorgement between feedings. This intervention addresses the root cause of the problem and promotes the client's comfort and breastfeeding success. Applying cold packs, using a supportive bra or breast binder, and administering oral analgesics may provide some relief for discomfort but do not address the underlying issue of engorgement.

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A patient with diabetes mellitus presents with polyuria, polydipsia, nocturia, and fatigue. Laboratory findings reveal hyperglycemia, glycosuria, and ketonuria. What is the most likely diagnosis?

  • A. Diabetic nephropathy
  • B. Diabetic ketoacidosis (DKA)
  • C. Hyperosmolar hyperglycemic state (HHS)
  • D. Diabetic autonomic neuropathy
Correct Answer: B

Rationale: The presentation of a patient with diabetes mellitus showing symptoms of polyuria, polydipsia, nocturia, and fatigue along with laboratory findings of hyperglycemia, glycosuria, and ketonuria is indicative of diabetic ketoacidosis (DKA). DKA is a serious complication of diabetes characterized by hyperglycemia, metabolic acidosis, and ketosis. The increased glucose levels lead to glycosuria, causing osmotic diuresis resulting in polyuria, polydipsia, and nocturia. The body starts breaking down fats for energy in the absence of sufficient insulin, leading to the production of ketones causing ketonuria. The patient may also experience fatigue due to the metabolic abnormalities present in DKA.

After positioning the patient for surgery, the nurse notices signs of pressure injury on the patient's heels. What should the nurse do?

  • A. Apply pressure-relieving devices to the heels
  • B. Document the findings in the patient's chart
  • C. Reposition the patient to relieve pressure
  • D. Notify the surgeon about the pressure injuries
Correct Answer: A

Rationale: Pressure injuries on the heels are a concern as they can develop quickly and lead to serious complications, especially in surgical patients who are immobile for extended periods. Applying pressure-relieving devices, such as heel protectors or foam dressings, can help alleviate the pressure on the affected areas and prevent further damage. These devices are designed to distribute pressure evenly and reduce the risk of pressure injuries. It is important for the nurse to address the issue promptly to prevent additional harm to the patient's skin integrity.

During the surgical procedure, the nurse notices a break in sterile technique by a member of the surgical team. What should the nurse do?

  • A. Document the break in sterile technique in the surgical log
  • B. Continue with the procedure and address the issue later
  • C. Inform the surgeon immediately and request corrective action
  • D. Report the incident to the hospital's quality assurance department
Correct Answer: C

Rationale: In this situation, it is crucial for the nurse to inform the surgeon immediately and request corrective action. Maintaining a sterile field during surgical procedures is essential to prevent infections and ensure patient safety. Any break in sterile technique should be addressed promptly to prevent any potential harm to the patient. By informing the surgeon immediately, corrective action can be taken promptly to maintain the sterility of the surgical field and minimize the risk of complications. Reporting the incident to the surgeon also allows for immediate intervention and re-education of the team member involved in the break in sterile technique.

A patient is prescribed a beta-blocker for the management of migraine headaches. Which adverse effect should the nurse monitor closely in the patient?

  • A. Hypertension
  • B. Bradycardia
  • C. Hyperglycemia
  • D. Constipation
Correct Answer: B

Rationale: Beta-blockers work by blocking the effects of adrenaline on beta receptors in the body. One common adverse effect of beta-blockers is bradycardia, or a slowed heart rate. Since the patient is being prescribed a beta-blocker for migraine headaches, it is important for the nurse to monitor closely for signs and symptoms of bradycardia such as dizziness, fatigue, and fainting. Monitoring the heart rate regularly and reporting any significant decrease to the healthcare provider is essential to prevent complications associated with bradycardia. Compared to the other options, bradycardia is the most relevant adverse effect to monitor in a patient prescribed a beta-blocker.

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 presentation of sudden-onset, painless vision loss in the right eye with a cherry-red spot at the macula and attenuated retinal vessels is classic for central retinal artery occlusion (CRAO). In this condition, the blockage of the central retinal artery results in severe ischemia of the retina, leading to rapid and profound vision loss. The cherry-red spot at the macula is a result of preserved choroidal circulation contrasting with the pale, ischemic retina. Attenuated retinal vessels are also commonly observed due to decreased blood flow. Prompt evaluation and management are critical in CRAO to potentially restore some vision and prevent further ischemic damage to the retina.

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