Adult Health Nursing Test Bank

Correct Answer: C

Rationale: The correct answer is C: Hyponatremia. SSRI medications can lead to the syndrome of inappropriate antidiuretic hormone secretion (SIADH), causing hyponatremia. This occurs due to increased levels of serotonin affecting the hypothalamus, leading to excessive ADH release. Hyponatremia can result in neurological symptoms and must be closely monitored. A: Bradycardia is not a common adverse effect of SSRIs. B: Hyperkalemia is not typically associated with SSRIs. D: Hypertension is not a common adverse effect of SSRIs; they may actually lower blood pressure.

Correct Answer: A

Rationale: In cases of uterine inertia, where weak and irregular contractions are causing slow cervical dilation during labor, administering intravenous oxytocin can help augment contractions and stimulate more effective progress. Oxytocin is a hormone that naturally stimulates uterine contractions and is commonly used in clinical settings to induce or enhance labor. By increasing the strength and frequency of contractions, oxytocin can help address uterine inertia and promote efficient cervical dilation to facilitate the progress of labor. It is important to monitor the response to oxytocin carefully to avoid complications such as hyperstimulation of the uterus, which can lead to fetal distress.

Correct Answer: A

Rationale: The correct response is A because it addresses the patient's concerns about potential discrimination. This shows empathy and understanding towards the patient's emotional well-being. Choices B, C, and D are incorrect because they do not directly address the patient's reasons for seeking an abortion. Choice B imposes moral and legal judgments, which can be insensitive. Choice C is not relevant to the patient's stated reason. Choice D imposes religious beliefs, which may not align with the patient's own beliefs.

Correct Answer: B

Rationale: The correct answer is B: Administer opioid analgesics to alleviate abdominal pain and discomfort. Opioid analgesics are effective in managing severe pain associated with malignant bowel obstruction. By providing adequate pain relief, the patient's comfort and quality of life can be significantly improved. Choice A is incorrect because initiating bowel rest and maintaining the patient in a semi-Fowler's position may not effectively address the severe pain and discomfort experienced by the patient. Choice C is incorrect as surgical intervention in this scenario may not be appropriate or feasible due to the advanced stage of cancer and the presence of malignant bowel obstruction. Choice D is incorrect as antiemetic medications primarily target nausea and vomiting, which may not be the primary symptoms of concern in this case. Focusing on pain management should be the priority.

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.