Adult Health Nursing Test Bank

Correct Answer: C

Rationale: Rationale: C is correct as keeping the ulcer covered with a sterile dressing provides a barrier against pathogens, promoting wound healing and preventing infection. A (topical antibiotics) can lead to resistance and disrupt normal flora. B (daily wound debridement) may introduce pathogens and delay healing. D (oral antibiotics prophylactically) is not recommended without evidence of infection.

Correct Answer: B

Rationale: The primary goal of CPR is to restore spontaneous circulation and oxygenation to the body to maintain vital organ function. By performing chest compressions and rescue breaths, CPR aims to circulate oxygenated blood to the brain and other vital organs. This is crucial to prevent brain damage and increase the chances of survival. The other choices are incorrect because CPR does not address the underlying cause of cardiac arrest (A), provide pain relief (C), or prevent further complications such as organ failure (D). The immediate focus in a cardiac arrest situation is to maintain blood flow and oxygen delivery to vital organs until advanced medical care can be provided.

Correct Answer: A

Rationale: The correct answer is A: Implement environmental modifications to promote sleep hygiene. Delirium is often triggered by environmental factors like noise, light, and disruption of sleep. By optimizing the environment for rest and minimizing stimuli, the patient's delirium can improve. This approach focuses on addressing the root cause rather than just managing symptoms. Choice B is incorrect because antipsychotic medications can worsen delirium and are not recommended as first-line treatment. Choice C is not the priority as ruling out focal deficits may be important but does not directly address the delirium. Choice D is incorrect as benzodiazepines can exacerbate delirium and are not recommended due to their potential to worsen cognitive function.

Correct Answer: A

Rationale: The correct answer is A because a viral illness few weeks before can trigger Guillain-Barre Syndrome (GBS) due to the body's immune response attacking the peripheral nerves. Encephalitis (B), severe bacterial infection (C), and meningitis (D) are not directly linked to GBS pathophysiology. Viral infections are known to precede GBS development, making choice A the most appropriate option.

Correct Answer: B

Rationale: The correct answer is B: Initiate non-invasive positive pressure ventilation (NIPPV) for respiratory support. In acute exacerbations of COPD, NIPPV helps improve ventilation and oxygenation, reducing the work of breathing and preventing the need for intubation. This intervention is a priority as it can rapidly stabilize the patient's respiratory status. A: Administering bronchodilator medications is important in COPD management, but in severe exacerbations, NIPPV takes precedence. C: Arterial blood gas analysis is important for assessing oxygenation and ventilation status, but it does not directly address the acute respiratory distress. D: Chest physiotherapy can help with airway clearance in COPD, but in acute exacerbations, respiratory support with NIPPV is more urgent.