Adult Health Med Surg Nursing Test Banks

Correct Answer: A

Rationale: Endometriosis is the most likely condition responsible for the symptoms described in this scenario. Endometriosis is a chronic condition in which endometrial-like tissue grows outside the uterus, commonly affecting the pelvic structures such as the ovaries, fallopian tubes, and pelvic peritoneum. The main symptoms include cyclic pelvic pain, dysmenorrhea (painful periods), and dyspareunia (pain during intercourse). The retroverted and fixed uterus on examination may be due to adhesions from endometriosis, causing the uterus to be fixed in position. Endometriosis should be considered in women of reproductive age presenting with these symptoms and pelvic examination findings.

Correct Answer: A

Rationale: Acute respiratory distress syndrome (ARDS) is a serious and life-threatening condition characterized by rapid onset of respiratory failure, severe hypoxemia (low oxygen levels in the blood), and non-cardiogenic pulmonary edema. The hallmark of ARDS is severe hypoxemia that is difficult to correct even with high levels of supplemental oxygen. Patients with ARDS often require mechanical ventilation to maintain adequate oxygen levels. Severe cough with purulent sputum production, chest pain exacerbated by deep breathing, and productive cough with hemoptysis are not typical features of ARDS.

Correct Answer: D

Rationale: The prioritized nursing intervention in this situation should be assessing for the risk of harm to self or infant. It is crucial to ensure the safety of the postpartum client and her infant as depression can increase the risk of self-harm or harm to the newborn. By assessing for any potential risks, the nurse can take appropriate actions to prevent any harm and ensure the well-being of both the client and the infant. Once the assessment is completed, further interventions like encouraging participation in support groups, referring to a mental health professional, or administering medications can be considered based on the assessment findings.

Correct Answer: C

Rationale: Benzodiazepines are commonly prescribed for the management of insomnia due to their sedative effects. One of the most common adverse effects of benzodiazepines is daytime drowsiness, which can impair the patient's ability to function normally during the day. Monitoring the patient closely for daytime drowsiness is important to ensure their safety and well-being, as it can affect their daily activities and increase the risk of accidents or falls. It is essential for the nurse to educate the patient on the potential for daytime drowsiness and advise them to avoid activities that require full alertness, such as driving or operating heavy machinery, until they know how the medication affects them. If the patient experiences severe or persistent daytime drowsiness, the healthcare provider may need to adjust the dosage or consider alternative treatment options.

Correct Answer: C

Rationale: Ms. Sanchez is violating the code of ethics for nurses. Nurses are expected to uphold professional behavior and maintain a positive public image. Endorsing a detergent product on TV Commercial wearing a mini skirt and a plunging neckline shirt may be seen as unprofessional and contrary to the image of a nursing professional. The code of ethics for nurses requires nurses to act with integrity, maintain professional boundaries, and avoid actions that could bring discredit to the profession. By engaging in this commercial, Ms. Sanchez is not upholding the ethical standards expected of nurses.