Adult Health Nursing Test Bank

Correct Answer: D

Rationale: The correct answer is D: Diabetic retinopathy. This condition is a common complication of diabetes that occurs due to the thickening of capillaries and arterioles in the eye, leading to damage to the retina. This can result in vision problems and even blindness if left untreated. A: Papilledema is the swelling of the optic disc due to increased intracranial pressure, not related to diabetes. B: Glaucoma is a condition characterized by increased pressure within the eye, not directly caused by diabetes. C: Retinal detachment is the separation of the retina from the underlying tissues, which is not primarily caused by diabetes-related capillary changes.

Correct Answer: B

Rationale: One potential maternal condition that may contribute to abnormal labor progression with slow cervical dilation despite regular contractions is pelvic outlet obstruction. This can occur if the maternal pelvis is too small, misshapen, or has an obstruction such as a fibroid tumor. The inadequate space in the pelvis can prevent the fetus from descending properly and can result in a prolonged or difficult labor. If suspected, interventions such as a cesarean delivery may be necessary to prevent complications for both the mother and baby. It is essential for the nurse to assess for signs of pelvic outlet obstruction and work with the healthcare team to address any issues promptly to ensure a safe delivery.

Correct Answer: A

Rationale: One potential complication of epidural analgesia in labor is maternal hypotension. The epidural analgesic can cause vasodilation, leading to a decrease in blood pressure. Maternal hypotension can result in decreased placental perfusion, which may jeopardize fetal well-being. It is important for healthcare providers to monitor the maternal blood pressure closely and intervene promptly if hypotension occurs by providing IV fluids or administering medication to raise blood pressure. Uterine hyperstimulation, fetal tachycardia, and respiratory depression are not typically associated with epidural analgesia as complications.

Correct Answer: C

Rationale: The correct answer is C: Secures clean ties before removing soiled ones. This is the priority action because securing clean ties prevents accidental dislodgement of the tracheostomy tube, ensuring the patient's airway remains patent. Cutting the dressing (A) or cleaning the incisions (B) can be important but not as critical as securing the tube. Using clean technique (D) is essential but not the priority in this situation.

Correct Answer: C

Rationale: The correct answer is C. Nurse Merry should tell the recruiter to give her more time to settle her personal affairs before departing to Canada. This is the best action because it shows responsibility and consideration for her current commitments and family situation. By requesting more time, she can prioritize her mother's recovery and complete her graduate studies, demonstrating good decision-making skills and care for her loved ones. Option A is incorrect because it dismisses the importance of family and personal obligations. Option B is incorrect as it shows a lack of planning and responsibility. Option D is incorrect as it suggests running away from problems instead of addressing them responsibly.