Adult Health Nursing Test Bank

Correct Answer: D

Rationale: The correct answer is D because confirming the insertion site and direction using imaging guidance ensures precise placement of the chest tube, minimizing the risk of complications. Imaging guidance allows the nurse to visualize the exact location of the pneumothorax and guide the tube insertion accurately. A: Positioning the patient in a semi-Fowler's position with arms elevated may be beneficial for comfort but does not directly ensure proper chest tube placement. B: Marking the insertion site with a pen may help as a reference point but does not guarantee accurate placement. C: Administering analgesia is important for the patient's comfort but does not impact the placement of the chest tube. In summary, choice D is the most critical step to ensure the chest tube is correctly placed and effectively treats the pneumothorax.

Correct Answer: C

Rationale: The correct answer is C: Anaphylaxis. Anaphylaxis is the MOST severe form of an allergic reaction, including latex allergy. It is a systemic, potentially life-threatening reaction that can involve multiple organ systems. Symptoms can include difficulty breathing, swelling of the throat, a rapid drop in blood pressure, and cardiovascular collapse. Pruritus, erythema, and swelling (choice A) are common symptoms of allergic reactions but not specific to anaphylaxis. Asthma (choice B) can be a manifestation of latex allergy but is not the most severe form. Blisters and other skin lesions (choice D) are not typical of anaphylaxis but can occur in some cases of contact dermatitis from latex exposure.

Correct Answer: B

Rationale: The correct answer is B because actively listening, acknowledging the patient's concerns, and working towards rebuilding trust through transparency and reliability are essential steps in addressing distrust. By validating the patient's experiences and actively involving them in the process, the nurse can foster a supportive and trusting relationship. Choice A is incorrect because dismissing the patient's concerns can further damage trust and undermine the patient's feelings. Choice C is incorrect as ignoring the distrust can lead to a breakdown in communication and trust. Choice D is incorrect because telling the patient to trust the healthcare system without addressing their concerns is dismissive and unhelpful.

Correct Answer: B

Rationale: The correct answer is B: Persons who have the disease. Sensitivity measures how well a test correctly identifies individuals who have the disease (true positives). It is essential in determining the test's ability to detect the presence of the disease accurately. Choices A, C, and D are incorrect because sensitivity focuses on correctly identifying individuals who have the disease, not those with symptoms, those without the disease, or those with a diagnosis of the disease.

Correct Answer: A

Rationale: The correct answer is A: Implement environmental modifications to promote sleep hygiene. Delirium is often triggered by environmental factors like noise, light, and disruption of sleep. By optimizing the environment for rest and minimizing stimuli, the patient's delirium can improve. This approach focuses on addressing the root cause rather than just managing symptoms. Choice B is incorrect because antipsychotic medications can worsen delirium and are not recommended as first-line treatment. Choice C is not the priority as ruling out focal deficits may be important but does not directly address the delirium. Choice D is incorrect as benzodiazepines can exacerbate delirium and are not recommended due to their potential to worsen cognitive function.