Adult Health Med Surg Nursing Test Banks

Correct Answer: D

Rationale: The prioritized nursing intervention in this situation should be assessing for the risk of harm to self or infant. It is crucial to ensure the safety of the postpartum client and her infant as depression can increase the risk of self-harm or harm to the newborn. By assessing for any potential risks, the nurse can take appropriate actions to prevent any harm and ensure the well-being of both the client and the infant. Once the assessment is completed, further interventions like encouraging participation in support groups, referring to a mental health professional, or administering medications can be considered based on the assessment findings.

Correct Answer: C

Rationale: Excessive bleeding during a surgical procedure is a critical situation that requires immediate attention. The surgeon should be notified promptly so that appropriate interventions can be initiated to control the bleeding, such as applying pressure, administering hemostatic agents, or performing additional surgical measures. The surgeon is ultimately responsible for addressing the source of bleeding and ensuring the patient's safety during the procedure. It is important for the nurse to communicate effectively and collaborate with the surgical team to manage the situation efficiently and effectively.

Correct Answer: C

Rationale: The presentation described is most consistent with a thyroid adenoma. Thyroid adenomas are benign neoplasms of the thyroid gland and can present as painless, gradually enlarging masses in the neck. Fine-needle aspiration cytology revealing thyroid follicular cells further supports the diagnosis of a thyroid adenoma. Thyroglossal duct cysts typically present as midline neck masses that move with swallowing, while lymphadenopathy presents as enlarged lymph nodes and may be associated with infection or malignancy. Thyroid carcinoma may also present as a neck mass but is more likely to be associated with other features such as vocal cord paralysis, hoarseness, or enlarged cervical lymph nodes.

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.

Correct Answer: A

Rationale: In the scenario described, the patient was considered an emergency case upon referral to the tertiary hospital. Since a specialist was immediately called for by the nurse, the most likely specialist needed in an emergency situation is a neurologist. Neurologists are physicians who specialize in diagnosing and treating disorders of the nervous system, including the brain, spinal cord, and nerves. In an emergency case where a patient's neurological condition needs urgent attention, a neurologist would be the most appropriate specialist to address the situation promptly and effectively.