Adult Health Med Surg Nursing Test Banks

Correct Answer: C

Rationale: Opioid medications are considered the first-line pharmacological treatment for dyspnea in palliative care patients with advanced cancer. Opioids help relieve dyspnea by reducing respiratory drive and the sensation of breathlessness, providing effective symptom management. In this case, addressing the patient's dyspnea with opioid medications would likely also help alleviate their anxiety related to breathlessness. Administering oxygen therapy (choice A) may not be effective at relieving dyspnea in this situation, as dyspnea in advanced cancer patients is often not primarily due to low oxygen levels. Teaching pursed-lip breathing techniques (choice B) and referring the patient to a respiratory therapist for breathing exercises (choice D) may be helpful complementary interventions, but opioid medications should be the priority for symptom management.

Correct Answer: C

Rationale: The initial step of delegation is to determine the competency level of the staff for the task being given. Before delegating a task, a nurse must assess the knowledge, skills, and abilities of the staff member to ensure that they are competent and capable of performing the task safely and effectively. This step is crucial in ensuring that tasks are delegated appropriately and that quality patient care is maintained. By determining the competency level of the staff, Nurse Gayle can make informed decisions about delegation, provide appropriate support and resources, and facilitate effective communication throughout the delegation process.

Correct Answer: A

Rationale: Colles' fracture is a type of distal radius fracture characterized by a break of the radius bone in the forearm close to the wrist. In a Colles' fracture, the distal fragment of the fractured radius bone gets displaced dorsally, meaning it shifts upwards towards the back of the hand, creating a characteristic "dinner fork" deformity when viewed from the side. This dorsal displacement results in a visible bump on the back of the wrist and a noticeable deformity when compared to the uninjured side.

Correct Answer: A

Rationale: The presentation of painless, progressive visual field loss, especially in the peripheral vision, along with an open iridocorneal angle is characteristic of open-angle glaucoma. Open-angle glaucoma is a type of glaucoma where there is no physical obstruction to the outflow of aqueous humor from the eye, but there is gradual damage to the optic nerve over time. The gradual loss of peripheral vision is a common early symptom of open-angle glaucoma. It is essential to diagnose and manage open-angle glaucoma promptly to prevent irreversible vision loss.

Correct Answer: C

Rationale: Uterine rupture is the most likely cause of these symptoms in a pregnant woman presenting with sudden onset of severe abdominal pain, vaginal bleeding, rigidity of the abdomen, and palpable fetal parts abdominally. Uterine rupture is a rare but serious complication of pregnancy, typically occurring during labor in women with a previous cesarean delivery or other uterine scars. The sudden onset of severe abdominal pain can be associated with vaginal bleeding due to the tearing of the uterine wall, causing fetal parts to be palpable abdominally. This is a life-threatening emergency that requires immediate medical intervention. Ectopic pregnancy, pelvic inflammatory disease, and ovarian torsion may present with abdominal pain and vaginal bleeding but would not typically present with palpable fetal parts abdominally in a pregnant woman.