Adult Health Med Surg Nursing Test Banks

Correct Answer: B

Rationale: The patient is presenting with symptoms consistent with cluster headache. Cluster headaches are characterized by recurrent episodes of severe unilateral (ipsilateral) headache accompanied by lacrimation (tearing from the eyes), rhinorrhea (runny nose), and ptosis (drooping of the eyelid). These headaches often occur in clusters over a period of weeks to months, hence the name "cluster headache."

Correct Answer: C

Rationale: Ethnographic research allows researchers to be neutral observers because it involves immersing oneself in the culture or community being studied without imposing their own biases or preconceptions. Ethnographers aim to understand the perspectives and behaviors of the people they are studying by observing them in their natural environment and engaging in participant observation. This approach enables researchers to gain insights into the social and cultural context of their subjects without influencing the outcomes or reactions. By maintaining neutrality and objectivity, ethnographic researchers can produce more authentic and unbiased results.

Correct Answer: C

Rationale: The symptoms described in the scenario - chest pain, dyspnea, and cyanosis - are indicative of a potential air embolism. Air embolism occurs when air enters the bloodstream, leading to blockages in blood vessels and impeding oxygen delivery to tissues. In patients receiving Total Parenteral Nutrition (TPN) through intravenous lines, the risk of air embolism exists during line manipulations, disconnections, or improper priming of the tubing. The sudden onset of symptoms like chest pain and cyanosis in a patient on TPN should raise suspicion for an air embolism, as it requires immediate intervention to prevent further complications such as cardiac arrest or stroke.

Correct Answer: B

Rationale: The nurse's best action in this situation would be to administer the ordered antibiotic trimethoprim (Trimpex). A urinary tract infection (UTI) requires antibiotic treatment to eliminate the bacterial infection causing the symptoms. Phenazopyridine hydrochloride is a urinary tract analgesic that can help relieve urinary pain but does not treat the infection itself. Bethanechol is a cholinergic medication used to treat urinary retention, not a UTI. Acetaminophen and a warm bath may help with some discomfort but do not address the underlying infection causing the urinary pain. Therefore, administering the prescribed antibiotic would be the most appropriate action to target the source of the patient's symptoms.

Correct Answer: C

Rationale: The most appropriate nursing action when a postpartum client presents with persistent, severe headache, photophobia, and altered mental status is to notify the healthcare provider immediately. These symptoms could be indicative of serious conditions such as postpartum preeclampsia or postpartum eclampsia, both of which require prompt medical evaluation and intervention. Delaying medical attention in such cases can lead to severe complications for the mother. Therefore, it is crucial to prioritize the client's safety and well-being by quickly involving the healthcare provider for further assessment and management.