Adult Health Nursing Test Bank

Correct Answer: D

Rationale: The correct answer is D: Ventricular tachycardia. Ventricular tachycardia is a serious arrhythmia that can lead to palpitations, dizziness, and syncope due to the rapid and abnormal heart rhythm originating in the ventricles. This arrhythmia can be life-threatening if not promptly treated. A: Stable angina is characterized by chest discomfort or pain due to reduced blood flow to the heart muscle, usually during physical exertion or stress. It does not typically present with palpitations, dizziness, or syncope. B: Unstable angina is a more severe form of angina where symptoms occur even at rest. While it can lead to serious complications like heart attack, it does not commonly present with palpitations, dizziness, or syncope. C: Atrial fibrillation is a common arrhythmia originating in the atria, leading to an irregular and often rapid heartbeat. While it can cause palpitations and dizziness,

Correct Answer: C

Rationale: The correct answer is C, to have a limited intake of sodium. Lithium can lead to increased sodium levels in the body, potentially causing toxicity. By limiting sodium intake, the patient can maintain a balance and prevent adverse effects. Choice A is incorrect as tyramine content is not directly related to lithium intake. Choice B is incorrect as fluid intake does not have a significant impact on lithium levels. Choice D is incorrect because an adequate intake of sodium can lead to worsening lithium toxicity.

Correct Answer: A

Rationale: The correct immediate action is to inform the surgeon and anesthesiologist (Choice A) because a sudden decrease in oxygen saturation during surgery is a critical situation that requires prompt attention from the entire surgical team. The surgeon and anesthesiologist need to be made aware of the situation so that they can assess the patient's condition and make any necessary adjustments to the surgical procedure or anesthesia delivery. Increasing the flow rate of oxygen (Choice B) may help temporarily but does not address the underlying cause of the oxygen desaturation. Checking the endotracheal tube placement (Choice C) is important but may not be the immediate priority in this critical situation. Assessing the patient's respiratory status (Choice D) is important but should be done after informing the surgeon and anesthesiologist to ensure coordinated and timely interventions.

Correct Answer: A

Rationale: Rationale: A is the correct answer as it demonstrates therapeutic communication by encouraging Annie to express her feelings and fears. It shows empathy and understanding, allowing Annie to elaborate on her concerns. B is incorrect as it dismisses Annie's fears and implies blame on her parenting. C is incorrect as it focuses on the behavior of the children rather than addressing Annie's emotions. D is incorrect as it places the responsibility on the children to make Annie feel comfortable, rather than addressing her concerns directly.

Correct Answer: B

Rationale: The correct answer is B: Provides reality orientation to patient. Orienting the patient to time, place, date, and events helps them stay connected to reality and improves their awareness of their surroundings. This is crucial in assessing their cognitive functioning and ensuring they are grounded in the present moment. By providing reality orientation, healthcare providers can better understand the patient's current mental state and address any potential confusion or disorientation. This approach aids in establishing a therapeutic environment and enhances the patient's overall well-being. Choices A, C, and D do not capture the essence of reality orientation and its significance in maintaining the patient's mental clarity and connection to the present moment.