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: Secures clean ties before removing soiled ones. This is the priority action because securing clean ties prevents accidental dislodgement of the tracheostomy tube, ensuring the patient's airway remains patent. Cutting the dressing (A) or cleaning the incisions (B) can be important but not as critical as securing the tube. Using clean technique (D) is essential but not the priority in this situation.

Correct Answer: C

Rationale: Step 1: Previous pregnancy experience is crucial for understanding the patient's obstetric history and potential risks. Step 2: It helps in identifying any complications or issues that may arise during the current pregnancy. Step 3: Laboratory results, prenatal check-up records, and diagnostic test results provide additional information but do not offer insights into the patient's past pregnancy experiences. Summary: Choice C is the most important as it directly relates to the patient's obstetric history, while the other options focus on current data that may not provide the same level of context.

Correct Answer: C

Rationale: The correct answer is C because communicating with the patient's primary care provider and community resources demonstrates continuity of care. This action ensures a seamless transition from the hospital to home by keeping all involved parties informed and involved in the patient's care. Option A (written discharge instructions only) may provide information but lacks coordination with other healthcare providers. Option B (discharging without follow-up care coordination) can lead to gaps in care. Option D (disregarding patient concerns) goes against patient-centered care and can disrupt the continuity of care.

Correct Answer: B

Rationale: The correct answer is B: Negligence. Negligence refers to the failure to exercise the care that a reasonably prudent person would under similar circumstances. In this case, administering the wrong dose of a vaccine indicates a lack of proper care or attention to detail, which constitutes negligence. A: Battery involves intentional harmful or offensive contact without consent, which is not applicable in this situation. C: Assault involves the threat of harm or unwanted physical contact, which is also not relevant here. D: Malpractice typically refers to professional misconduct or negligence by a healthcare provider, which could be a broader term but not specific to the situation described.