Foundations and Adult Health Nursing Test Bank

Correct Answer: B

Rationale: The patient's presentation with renal failure, confusion, seizures, asterixis, and a sweet odor to the breath, along with laboratory findings of severe metabolic acidosis, hyperkalemia, and elevated BUN and creatinine levels, is consistent with uremic encephalopathy. Uremic encephalopathy is a neurological complication of acute or chronic renal failure resulting from the buildup of uremic toxins in the blood, leading to various neurological symptoms such as confusion and seizures. The sweet odor to the breath can be attributed to the presence of urea, a waste product that accumulates in renal failure. Other metabolic abnormalities like hyperkalemia and severe metabolic acidosis are also common in renal failure. It is crucial to promptly recognize and manage uremic encephalopathy to prevent further neurological complications.

Correct Answer: A

Rationale: Troponin is the most specific cardiac biomarker for myocardial injury. Troponin I and Troponin T are proteins released into the bloodstream when there is damage to the heart muscle, making them highly indicative of myocardial infarction. Troponin levels rise within a few hours of cardiac injury, peak within 24-48 hours, and can remain elevated for up to 2 weeks. Troponin is considered the gold standard biomarker for the diagnosis of acute myocardial infarction due to its high specificity and sensitivity for cardiac injury. In contrast, Creatine kinase-MB (CK-MB) and myoglobin are also used in diagnosing myocardial infarction but are less specific than troponin. Brain natriuretic peptide (BNP) is primarily used in heart failure diagnosis and management, and its levels are not specific to myocardial injury.

Correct Answer: A

Rationale: The patient's presentation of sudden-onset, painless vision loss in the right eye, along with a cherry-red spot at the macula and attenuated retinal vessels, is classic for central retinal artery occlusion (CRAO). In CRAO, there is a sudden blockage of the central retinal artery, leading to ischemia of the retina. The cherry-red spot represents the preserved choroid blood flow against the ischemic retina. The attenuated retinal vessels are a result of decreased blood flow in the retinal circulation. This condition is considered an ophthalmic emergency and requires immediate evaluation and management to prevent permanent vision loss.

Correct Answer: C

Rationale: If the nurse notices that the patient's arms are not adequately padded while positioning for surgery, the nurse should immediately take action to prevent pressure injuries. Applying soft padding to the patient's arms will help distribute the pressure more evenly, reducing the risk of skin breakdown and potential harm to the patient during the surgical procedure. It is essential to prioritize the patient's safety and comfort in such situations. Simply proceeding with the positioning as planned could lead to complications, so addressing the inadequate padding promptly is the appropriate course of action.

Correct Answer: C

Rationale: NSAIDs are known to increase the risk of gastrointestinal complications, particularly gastrointestinal bleeding, ulcers, and perforation. This risk is higher in patients who are elderly, have a history of peptic ulcer disease, are taking high doses of NSAIDs, or are using them for a prolonged period. It is important for the nurse to closely monitor the patient for signs and symptoms of gastrointestinal bleeding, such as abdominal pain, black or tarry stools, vomiting blood, and anemia. Prompt identification and management of these complications are essential to prevent serious consequences. Monitoring for gastrointestinal adverse effects is crucial when a patient is prescribed NSAIDs for managing conditions like osteoarthritis.