Adult Health Nursing Test Bank

Correct Answer: A

Rationale: The correct answer is A: Muscle pain or weakness. Statins can cause muscle-related side effects, including rhabdomyolysis, a severe condition that can lead to muscle pain and weakness. Monitoring for these symptoms is crucial to prevent serious complications. B: Dry cough is not a common side effect of statins. C: Hypertension is not directly associated with statin use. D: Hyperkalemia is not a typical adverse effect of statins.

Correct Answer: A

Rationale: The correct answer is A: Malpractice. The nurse's failure to document and remove the over-the-counter medication, which led to a serious adverse drug reaction, constitutes malpractice. Malpractice refers to negligence or failure to provide the standard of care expected in a professional setting. In this case, the nurse's actions directly resulted in harm to the client, which is a clear example of malpractice. Incorrect Choices: B: Failure of duty to warn - This choice implies that the nurse had a duty to warn the client about the potential drug interaction, which may not necessarily be the case. The primary issue here is the nurse's failure to document and remove the medication, not a failure to warn. C: Assault - Assault involves intentional harm or threat of harm, which is not applicable in this scenario where the harm was due to negligence. D: Incompetence - While the nurse's actions may demonstrate incompetence, the more specific legal term for this situation would be malpractice, as it directly

Correct Answer: A

Rationale: The correct answer is A: Bleeding. Chemotherapy can lead to low platelet counts (thrombocytopenia), increasing the risk of bleeding. The priority goal of the nurse is to prevent bleeding by taking precautions such as avoiding invasive procedures, using soft toothbrushes, and monitoring for signs of bleeding. Infection (B) is important but not the priority as bleeding can be life-threatening. Hypotension (C) is not directly related to thrombocytopenia. Diarrhea (D) is a potential side effect of chemotherapy but is not the priority when considering thrombocytopenia.

Correct Answer: D

Rationale: The correct answer is D: Trigeminal neuralgia. This condition is characterized by recurrent, severe, stabbing pain in the trigeminal nerve distribution triggered by touch, chewing, or cold exposure. The key feature is the characteristic lancinating pain, which is not typical of migraine (choice A), cluster headache (choice B), or tension-type headache (choice C). Migraine typically presents with pulsating, moderate to severe headache associated with nausea and sensitivity to light and sound. Cluster headache is characterized by severe, unilateral pain around the eye associated with autonomic symptoms. Tension-type headache presents with bilateral, pressing or tightening pain without specific triggers. Therefore, based on the description of the symptoms in the question, trigeminal neuralgia is the most likely diagnosis.

Correct Answer: C

Rationale: The correct answer is C because communicating with the patient's primary care provider and community resources demonstrates continuity of care. This action ensures a seamless transition from the hospital to home by keeping all involved parties informed and involved in the patient's care. Option A (written discharge instructions only) may provide information but lacks coordination with other healthcare providers. Option B (discharging without follow-up care coordination) can lead to gaps in care. Option D (disregarding patient concerns) goes against patient-centered care and can disrupt the continuity of care.