Adult Health Med Surg Nursing Test Banks

Correct Answer: B

Rationale: Disseminated intravascular coagulation (DIC) is a condition characterized by widespread activation of coagulation leading to both thrombosis and hemorrhage. In patients with chronic liver disease, especially in the setting of advanced cirrhosis, DIC can develop due to factors such as decreased synthesis of coagulation factors and impaired clearance of activated clotting factors. The patient in this scenario presents with signs of both abnormal bleeding (bruising, petechiae, mucosal bleeding) and laboratory findings consistent with DIC, including prolonged prothrombin time (PT) and activated partial thromboplastin time (aPTT) along with decreased platelet count.

Correct Answer: B

Rationale: A prolapsed umbilical cord is a medical emergency during labor because it can cause compression of the umbilical cord, leading to decreased oxygen supply to the fetus. The priority nursing action in this situation is to prepare for an immediate cesarean section. This is necessary to quickly deliver the baby and relieve pressure on the cord, preventing potential fetal distress or death. Elevating the mother's hips may help reduce pressure on the cord temporarily, but it is not the definitive treatment for a prolapsed cord. Administering intravenous fluids rapidly may be necessary, but it is not the priority intervention when the fetus is at risk due to a prolapsed cord. Performing a vaginal examination to assess cervical dilation is contraindicated in the presence of a prolapsed umbilical cord as it can further compress the cord and worsen the situation.

Correct Answer: A

Rationale: Immunological memory is primarily maintained by the clonal expansion of memory B cells. Memory B cells are a type of long-lived immune cell that originates from previously activated B cells during an immune response to a pathogen. When the immune system encounters the same pathogen again, memory B cells can quickly recognize and respond to it by undergoing rapid clonal expansion and differentiation into plasma cells that produce specific antibodies. This quick and robust response leads to the more efficient elimination of the pathogen during secondary exposure, resulting in the faster and stronger immune response characteristic of immunological memory.

Correct Answer: A

Rationale: Immersing oneself in the local community and participating in their everyday activities allows the nurse, as a community organizer, to establish trust and build rapport with the people. By actively engaging with the community members, the nurse can show genuine interest and commitment to their well-being, which fosters a sense of connection and mutual understanding. This approach is crucial for gaining the trust of the community, as it demonstrates that the nurse is invested in listening to their needs and working together to address health concerns effectively.

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