Adult Health Med Surg Nursing Test Banks

Correct Answer: A

Rationale: The patient's presentation of recurrent episodes of sudden, severe vertigo lasting hours with nausea, vomiting, and nystagmus, along with unilateral weakness on vestibular function tests, is most consistent with vestibular neuritis. Vestibular neuritis is characterized by inflammation of the vestibular nerve leading to sudden onset vertigo that can last for hours to days. It is often associated with nausea, vomiting, and nystagmus. Unilateral weakness on vestibular function tests indicates dysfunction of one vestibular system. Differential diagnosis for this type of presentation includes other conditions such as Meniere's disease, BPPV, and acoustic neuroma. However, the combination of symptoms and unilateral vestibular weakness makes vestibular neuritis the most likely diagnosis in this case.

Correct Answer: B

Rationale: Hip dysplasia is a common complication associated with untreated clubfoot in infants. If clubfoot is not treated promptly and properly, it can lead to abnormal development of the hip joint, resulting in hip dysplasia. This condition involves the abnormal formation of the hip socket, which can cause instability and potential dislocation of the hip joint. Early identification and treatment of clubfoot are important in preventing complications such as hip dysplasia.

Correct Answer: B

Rationale: When a patient arrives in the emergency room, the nurse's first priority is to assess the patient's airway, breathing, and circulation, following the ABCs of emergency care. In this scenario, positioning the patient with the head lower than the extremities ensures proper blood flow to vital organs, especially the brain. This position helps to maintain perfusion to the brain and prevent complications such as hypotension and shock. Once the patient's position is optimized, the nurse can proceed with further interventions such as starting an intravenous line, stopping bleeding, and requesting laboratory examinations as needed.

Correct Answer: B

Rationale: Normal saline is the preferred solution for wound irrigation because it is isotonic and will not damage healthy tissue or delay wound healing. It helps to remove debris and pathogens from the wound, promoting a clean environment for healing. Sterile water can be used if normal saline is not available, but it may cause cellular damage if used in large volumes. Hydrogen peroxide and Betadine solution are not recommended for wound irrigation as they can be cytotoxic to the tissues and interfere with the wound healing process. It's important for the nurse to use evidence-based practice and follow recommended guidelines to promote optimal wound healing outcomes.

Correct Answer: A

Rationale: Nicotine, a substance found in cigarettes, is known to have harmful effects on pregnancy. Smoking during pregnancy can lead to numerous complications, one of which is the increased risk of delivering a low birth weight infant. Low birth weight infants are born weighing less than 5.5 pounds (2.5 kilograms) and are at a higher risk of various health issues, developmental delays, and even mortality. Therefore, Nurse Emma advised the patient to quit smoking to reduce the risk of having a low birth weight infant.