Adult Health Med Surg Nursing Test Banks

Correct Answer: B

Rationale: Postural hypotension, also known as orthostatic hypotension, is a common issue postpartum and can cause lightheadedness when standing up. When a postpartum client expresses concern about feeling lightheaded, assessing for postural hypotension should be a priority. This assessment involves measuring the client's blood pressure while lying down, sitting, and standing to identify any significant drops in blood pressure upon changing positions. Identifying postural hypotension early allows for appropriate interventions to prevent potential falls and address the client's symptoms. Checking blood pressure, evaluating hemoglobin levels, and monitoring for signs of hemorrhage are also important assessments but may not directly address the specific issue of feeling lightheaded when standing up in this scenario.

Correct Answer: D

Rationale: Thrombocytopenia is a condition characterized by a low platelet count, which can lead to an increased risk of bleeding. Patients with thrombocytopenia are at risk for injury due to potential bleeding complications. Therefore, the appropriate nursing diagnosis to protect the patient from further injury in this case would be "Risk for injury related to thrombocytopenia." This nursing diagnosis allows the nurse to assess for signs of bleeding, implement interventions to prevent injury, and closely monitor the patient's platelet levels to prevent complications.

Correct Answer: D

Rationale: Third-degree perineal lacerations are significant injuries that require careful monitoring for signs of infection or wound dehiscence, which are potential complications that could hinder optimal wound healing. Signs of infection may include increased redness, warmth, swelling, pain, and purulent drainage from the wound site. Dehiscence refers to the separation of the wound edges, which can be a serious complication requiring immediate attention. By closely monitoring the incision site for these signs, the nurse can promptly intervene if any complications arise, ensuring proper healing and preventing further complications. While providing perineal care, proper application of peri-pads, and encouraging sitz baths are important for comfort and cleanliness, monitoring for complications takes priority in promoting optimal wound healing in this scenario.

Correct Answer: A

Rationale: The presentation described is consistent with anterior uveitis. Anterior uveitis involves inflammation of the iris and ciliary body. Patients typically present with symptoms such as redness, pain, photophobia, and blurred vision. The slit-lamp examination findings of ciliary injection (redness and dilation of blood vessels in the iris and ciliary body), corneal edema, and a mid-dilated pupil with a fixed reaction to light (due to ciliary muscle spasm causing decreased accommodation) are characteristic of anterior uveitis. This condition is often idiopathic but can be associated with various systemic diseases like ankylosing spondylitis, inflammatory bowel disease, and other autoimmune disorders. Treatment involves addressing the inflammation with topical corticosteroids and, in some cases, cycloplegic agents to reduce pain and inflammation.

Correct Answer: A

Rationale: The clinical presentation of gross hematuria, flank pain, palpable abdominal mass, along with imaging findings of a large heterogeneous renal mass with necrosis and calcifications are highly suggestive of renal cell carcinoma (RCC). RCC is the most common type of kidney cancer in adults. The presence of necrosis and calcifications are characteristic features of RCC. Imaging modalities such as CT scans or MRI can confirm the diagnosis by showing the typical features of RCC, including a solid mass with areas of necrosis and calcifications. It is important to further evaluate this patient, likely with a biopsy, to confirm the diagnosis and determine the extent of the disease for appropriate management.