Adult Health Nursing Test Banks

Correct Answer: C

Rationale: Persistent, severe abdominal pain, tenderness, and rigidity in a postpartum client can be indicative of serious conditions such as uterine rupture, hemorrhage, or infection, which require urgent medical attention. As a nurse, the priority action in this situation is to notify the healthcare provider immediately so that appropriate interventions can be initiated promptly to ensure the safety and well-being of the client. Administering analgesics or providing emotional support may not address the underlying cause of the symptoms and could potentially delay necessary medical treatment. Assisting the client to a comfortable position can be considered once the healthcare provider has been informed and appropriate assessments and interventions have been initiated.

Correct Answer: A

Rationale: The combination of recurrent joint pain, swelling, and limited range of motion in multiple joints along with elevated ESR, positive RF, and presence of anti-CCP antibodies is classic for rheumatoid arthritis (RA). Elevated ESR indicates inflammation, positive rheumatoid factor (RF) is an autoantibody commonly found in the serum of patients with RA, and the presence of anti-cyclic citrullinated peptide (anti-CCP) antibodies further supports the diagnosis of RA. These laboratory findings along with the clinical presentation are highly suggestive of rheumatoid arthritis. Systemic lupus erythematosus (SLE), ankylosing spondylitis (AS), and psoriatic arthritis (PsA) can have overlapping symptoms with RA, but the specific combination of elevated ESR, positive RF, and anti-CCP antibodies points more towards RA in this scenario.

Correct Answer: C

Rationale: The correct response for the nurse in this situation would be to offer the victim a shower after evidence is collected. It is essential to preserve any physical evidence that may be present from the assault during the forensic examination. Allowing the victim to shower before evidence is collected could potentially compromise the evidence and hinder the investigation. The nurse should provide support to the victim during this difficult time and assure them that they will have the opportunity to shower once the necessary evidence is obtained. It is also crucial for the nurse to offer empathy and understanding while explaining the importance of preserving any evidence related to the assault.

Correct Answer: D

Rationale: Sonography, also known as ultrasound, is a non-invasive imaging technique that uses high-frequency sound waves to create images of structures inside the body. In the context of a patient who is pregnant, sonography is commonly used to assess the well-being of the fetus. It allows healthcare providers to monitor the growth and development of the fetus, evaluate the placenta, amniotic fluid levels, and detect any abnormalities that may be present.

Correct Answer: A

Rationale: Sherry is a type of fortified wine produced in Spain. It is not associated with the development of hyperkalemia, which is a condition characterized by high levels of potassium in the blood. Hyperkalemia is commonly caused by kidney dysfunction, certain medications, or excessive intake of potassium-rich foods. Drinking Sherry is not likely to cause hyperkalemia. On the other hand, Sherry consumption can potentially contribute to tooth decay, gastric ulcers, and rectal bleeding due to its acidity and alcohol content.