Foundations and Adult Health Nursing Test Bank

Correct Answer: D

Rationale: The presentation of sudden-onset severe headache, vomiting, and altered mental status, along with the presence of a berry-shaped aneurysm on imaging, point towards a diagnosis of subarachnoid hemorrhage. The most common cause of a subarachnoid hemorrhage is the rupture of a saccular (berry) aneurysm, which commonly occurs at the junction of the anterior communicating artery and anterior cerebral artery. The sudden headache is often described as the "worst headache of my life" and is typically associated with nausea and vomiting. Altered mental status may be present due to the effects of increased intracranial pressure and possible associated brain injury. It is important to promptly diagnose and manage subarachnoid hemorrhage to prevent complications such as vasospasm, rebleeding, and ischemic deficits.

Correct Answer: B

Rationale: Being assertive means expressing one's thoughts, beliefs, and feelings in a confident and respectful manner while also considering the perspective of others. It does not involve pushing control on others. Assertive individuals do not impose their beliefs on others but express themselves clearly and confidently, respecting the opinions of others. So, standing up for what one believes in can be assertive, but pushing control on others is not a characteristic of assertiveness.

Correct Answer: D

Rationale: Ensuring the availability of emergency equipment and resuscitation medications is crucial to prioritize patient safety during a transesophageal echocardiogram (TEE) procedure. TEE involves inserting a specialized probe (transducer) into the esophagus to obtain detailed images of the heart. While complications during TEE are rare, they can include adverse reactions to sedation, esophageal injury, arrhythmias, or other cardiac events. By having emergency equipment and resuscitation medications readily available, the healthcare team can respond promptly to any unforeseen complications or emergencies that may arise during the procedure, ensuring optimal patient safety. Placing the patient in a supine position, providing sedation, and advising the patient to fast before the procedure are important aspects of the TEE process; however, ensuring emergency preparedness takes precedence in prioritizing patient safety during the procedure.

Correct Answer: A

Rationale: The nurse should prioritize using sterile technique during the tracheostomy tube change to ensure patient safety. Tracheostomy procedures involve a direct entry into the airway, making it crucial to prevent infection and reduce the risk of complications. Sterile technique, including proper hand hygiene, wearing sterile gloves, and using sterile equipment, helps minimize the introduction of pathogens into the patient's airway, reducing the risk of infection. By maintaining a sterile field, the nurse can protect the patient from potential harm and promote a successful outcome of the tracheostomy tube change.

Correct Answer: B

Rationale: The nurse's best approach to address the patient's fear of pain is to provide accurate information about pain management strategies and options. In doing so, the nurse can help alleviate the patient's concerns by empowering them with knowledge and potential solutions for managing pain during and after the procedure. By acknowledging the patient's fear and addressing it with practical information, the nurse can build trust, reduce anxiety, and create a more supportive and collaborative environment for the patient. Dismissing, ignoring, or invalidating the patient's fear would not be effective in addressing the underlying concerns and could potentially lead to increased distress and resistance to the recommended procedure.