Adult Health Med Surg Nursing Test Banks

Correct Answer: C

Rationale: Pituitary adenoma is the most likely neurological condition responsible for the described symptoms of acute onset severe headache, visual disturbances, and altered mental status when a tumor is found compressing the optic chiasm. Pituitary adenomas are benign tumors arising from the pituitary gland located at the base of the brain. As the tumor grows, it can compress nearby structures such as the optic chiasm, leading to visual disturbances (due to pressure on the optic nerves), severe headache (due to increased intracranial pressure), and altered mental status (due to effects on nearby brain structures).

Correct Answer: A

Rationale: A patient with a severe viral infection exhibiting reduced levels of circulating lymphocytes is likely due to the apoptosis of infected lymphocytes. When a virus enters the body, it can infect and replicate within lymphocytes, subsequently triggering the immune system to induce apoptosis in infected cells to prevent further spread of the virus. This process is part of the body's defense mechanism to control the viral infection. As a result, the circulating lymphocyte levels may decrease as infected lymphocytes are targeted for apoptosis. This phenomenon helps to limit viral replication and spread within the body, thereby aiding in the immune response to eliminate the virus.

Correct Answer: B

Rationale: The nurse's best response when a patient expresses frustration with the healthcare system's inefficiencies is to listen actively to the patient's concerns, acknowledge the challenges they are facing, and offer support. It is important for the nurse to validate the patient's feelings and demonstrate empathy, rather than dismissing or ignoring their frustrations. By offering support and showing understanding, the nurse can help the patient feel heard and valued, which is an essential aspect of providing patient-centered care. This approach can also help to strengthen the nurse-patient relationship and build trust, ultimately leading to better outcomes for the patient's overall healthcare experience.

Correct Answer: A

Rationale: When a baby is placed on phototherapy, especially for treating jaundice, it is crucial for the nurses to put sunglasses on the newborn to protect their eyes. Phototherapy involves exposing the baby's skin to certain types of light to help break down the bilirubin causing the jaundice. However, this light can be harmful to the baby's sensitive eyes, potentially leading to eye damage or other eye-related issues if not protected adequately. Therefore, placing sunglasses on the newborn is a necessary precaution to ensure the safety and well-being of the baby's eyes during the treatment.

Correct Answer: D

Rationale: When a postpartum client exhibits signs of postpartum psychosis such as hallucinations, delusions, and disorganized behavior, it is crucial to involve the healthcare provider immediately. Postpartum psychosis is a psychiatric emergency that requires prompt assessment and intervention by mental health professionals. The healthcare provider can determine the appropriate course of action, which may include hospitalization, medication management, and specialized psychiatric care. Delaying notification can lead to serious consequences for both the client and her infant, so timely intervention is essential in managing postpartum psychosis.