Adult Health Med Surg Nursing Test Banks

Correct Answer: A

Rationale: The patient's presentation of recurrent episodes of sudden, severe vertigo lasting hours, along with nausea, vomiting, nystagmus, and unilateral weakness on vestibular function tests, is most consistent with vestibular neuritis. Vestibular neuritis is an inflammatory disorder of the vestibular nerve, typically viral in origin, leading to acute onset of vertigo. Patients often experience severe vertigo, imbalance, nausea, and vomiting, along with characteristic nystagmus. Unilateral weakness on vestibular function testing supports the diagnosis of vestibular neuritis, as it indicates dysfunction of one vestibular organ. Benign paroxysmal positional vertigo (BPPV) typically presents with brief episodes of vertigo triggered by changes in head position without associated unilateral vestibular weakness. Ménière's disease is characterized by recurrent episodes of vertigo associated with fluctuating hearing loss, tinnitus, and aural fullness, and

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: 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: Using an expired skin preparation solution can compromise the safety and effectiveness of the surgical site cleansing. Expired solutions may have reduced efficacy or could cause adverse reactions due to chemical breakdown over time. Therefore, it is essential for the nurse to discard the expired solution and obtain a new one to ensure proper sanitation and reduce the risk of complications during the surgical procedure. It is important to adhere to proper protocols and guidelines in healthcare settings to maintain patient safety and optimal outcomes.

Correct Answer: D

Rationale: Third-degree perineal lacerations are significant injuries that require careful monitoring for signs of infection or wound dehiscence, which are potential complications that could hinder optimal wound healing. Signs of infection may include increased redness, warmth, swelling, pain, and purulent drainage from the wound site. Dehiscence refers to the separation of the wound edges, which can be a serious complication requiring immediate attention. By closely monitoring the incision site for these signs, the nurse can promptly intervene if any complications arise, ensuring proper healing and preventing further complications. While providing perineal care, proper application of peri-pads, and encouraging sitz baths are important for comfort and cleanliness, monitoring for complications takes priority in promoting optimal wound healing in this scenario.