Adult Health Nursing Test Bank

Correct Answer: C

Rationale: The correct answer is C: Meningitis. The patient's symptoms of severe headache, photophobia, neck stiffness, nuchal rigidity, and positive Kernig and Brudzinski signs are classic signs of meningitis. Meningitis is an inflammation of the meninges surrounding the brain and spinal cord, leading to these specific neurological symptoms. Migraine headache (A) typically presents with a throbbing headache, nausea, and sensitivity to light and sound, but does not typically cause neck stiffness or positive meningeal signs. Cluster headache (B) is characterized by severe unilateral headache with autonomic symptoms like tearing or nasal congestion, but does not typically cause neck stiffness or positive meningeal signs. Subarachnoid hemorrhage (D) presents with sudden severe headache often described as "the worst headache of my life," and may cause neck stiffness, but typically does not present with photophobia or positive meningeal signs like Kernig and Brudzinski signs.

Correct Answer: C

Rationale: The correct answer is C because providing emotional support and offering counseling or therapy sessions address the root cause of the patient's depression in a holistic manner. This intervention allows the patient to express their emotions, process their feelings, and receive guidance on coping strategies. Encouraging social activities (A) may not directly address the underlying emotional issues. Referring to a psychiatrist for medication (B) should be considered if counseling alone is insufficient. Exploring spiritual beliefs (D) is important but may not be the most immediate priority for addressing depression in this context.

Correct Answer: C

Rationale: The correct answer is C because encouraging the patient to ask questions and express concerns promotes patient empowerment and active participation in self-care. This approach fosters communication, understanding, and collaboration between the nurse and patient, leading to better medication adherence. Choice A is incorrect as it lacks patient involvement. Choice B is helpful but does not necessarily empower the patient. Choice D is directive and does not encourage active participation or empowerment.

Correct Answer: B

Rationale: The correct answer is B because actively listening, acknowledging the patient's concerns, and working towards rebuilding trust through transparency and reliability are essential steps in addressing distrust. By validating the patient's experiences and actively involving them in the process, the nurse can foster a supportive and trusting relationship. Choice A is incorrect because dismissing the patient's concerns can further damage trust and undermine the patient's feelings. Choice C is incorrect as ignoring the distrust can lead to a breakdown in communication and trust. Choice D is incorrect because telling the patient to trust the healthcare system without addressing their concerns is dismissive and unhelpful.

Correct Answer: A

Rationale: Encouraging early ambulation and progressive activity as tolerated is the most appropriate nursing intervention to promote optimal recovery for a postpartum client who delivered via cesarean section. Early ambulation helps prevent complications such as blood clots, pneumonia, and constipation. It also promotes circulation and facilitates healing by reducing the risk of postoperative complications. Progressive activity helps the client regain strength, mobility, and independence, which are essential for a speedy recovery. Restoring normal movement will also help decrease discomfort and improve the client's overall well-being. In contrast, restricting movement may lead to complications and delayed recovery. Administering oral analgesics as needed is important for pain management, but promoting early ambulation is essential for optimal recovery. Heat packs should not be applied to the incision site as they can increase the risk of infection and interfere with proper wound healing.