Adult Health Nursing Test Banks

Correct Answer: B

Rationale: The patient's presenting symptoms of chest pain worsened by inspiration and relieved by sitting forward, with associated DVT in the lower extremity, suggest a high likelihood of pulmonary embolism. Chest pain that worsens with inspiration due to pleuritic involvement is a classic symptom of pulmonary embolism. Additionally, the presence of DVT in the lower extremity represents a risk factor for the development of pulmonary embolism, as clots originating in the deep veins can travel to the pulmonary circulation to cause an obstruction. Patients with pulmonary embolism may also exhibit signs of right heart strain, such as tachycardia, tachypnea, and sometimes hemoptysis.

Correct Answer: C

Rationale: The element involved when a nurse initiates interpersonal communication is the sender. In the communication process, the sender is the person who initiates the message or information to be conveyed to the receiver. In this case, the nurse is taking on the role of the sender by initiating the communication with the patient, another healthcare professional, or any other individual. The sender is responsible for encoding the message and selecting the appropriate channel to convey it effectively. Therefore, in this scenario, the nurse is the one initiating communication, making her the sender in the communication process.

Correct Answer: B

Rationale: Beta-blockers work by blocking the effects of adrenaline on beta receptors in the body. One common adverse effect of beta-blockers is bradycardia, or a slowed heart rate. Since the patient is being prescribed a beta-blocker for migraine headaches, it is important for the nurse to monitor closely for signs and symptoms of bradycardia such as dizziness, fatigue, and fainting. Monitoring the heart rate regularly and reporting any significant decrease to the healthcare provider is essential to prevent complications associated with bradycardia. Compared to the other options, bradycardia is the most relevant adverse effect to monitor in a patient prescribed a beta-blocker.

Correct Answer: D

Rationale: Nurse Rey can be liable for committing malpractice. Malpractice refers to professional negligence or failure to provide the standard of care expected in a particular medical situation. In this scenario, Nurse Rey is not qualified or authorized to perform circumcisions, as it falls outside of the scope of practice for a nurse. By participating in performing circumcisions without the necessary qualifications and training, Nurse Rey is potentially putting patients at risk and not providing the appropriate standard of care expected from a healthcare professional. This could be considered as malpractice, for which Nurse Rey may be held liable.

Correct Answer: B

Rationale: First-voided morning urine is the best urine sample to be used for an accurate result of a pregnancy test done at home because it is more concentrated compared to urine samples collected at other times of the day. Overnight, the hCG hormone (human chorionic gonadotropin) builds up in a woman's body, making the early morning urine more likely to contain higher levels of hCG if a woman is pregnant. The concentrated nature of first-morning urine reduces the chances of false-negative results since it provides a higher concentration of the hormone that the test is designed to detect. Therefore, using first-morning urine increases the sensitivity of the pregnancy test and improves the accuracy of the results.