Adult Health Nursing Test Banks

Correct Answer: C

Rationale: The presence of persistent, severe perineal pain along with ecchymosis and swelling of the perineum can indicate a complication such as a hematoma. A hematoma is a collection of blood that can occur in the perineal area postpartum, usually as a result of trauma during delivery. It is essential to notify the healthcare provider immediately to assess the situation, provide appropriate treatment, and prevent further complications. Applying ice packs or administering additional analgesic medication may not address the underlying issue of a possible hematoma, so prompt medical evaluation is crucial in this situation.

Correct Answer: A

Rationale: Battery refers to the intentional and offensive physical contact with another person without their consent, resulting in harm or injury. In this scenario, the victim clearly expressed their unwillingness to be touched or helped by saying, "Don't touch me!" multiple times. By ignoring the victim's refusal and physically forcing them into the ambulance, the EMT is committing battery even though they may have had good intentions to provide assistance. It is important for medical professionals, including EMTs, to always respect a person's right to refuse medical treatment or assistance, even in emergency situations.

Correct Answer: A

Rationale: The described presentation is classic for acute angle-closure glaucoma. This condition is characterized by sudden-onset severe eye pain, headache, nausea, and vomiting. The red eye, steamy cornea (corneal edema), and mid-dilated non-reactive pupil are consistent with acute angle-closure glaucoma. The sudden increase in intraocular pressure leads to impaired aqueous humor outflow, causing these symptoms. Immediate intervention is required to prevent permanent vision loss in such cases. Central retinal artery occlusion would present with sudden painless vision loss. Optic neuritis typically presents with vision loss and pain with eye movements. Corneal ulcer presents with eye discomfort, foreign body sensation, and may have a history of corneal trauma or contact lens wear.

Correct Answer: A

Rationale: In cases of poisoning, the main goals are to inactivate the poison to prevent further harm, administer the specific antidote if available to counteract the effects of the poison, and support vital organ functions to help the patient recover. Inducing the patient to vomit (III) is not always recommended as it can potentially cause more harm, especially if the ingested substance is corrosive. Therefore, the most appropriate goals in poisoning are to inactivate the poison, administer the specific antidote, and support vital organ functions.

Correct Answer: B

Rationale: In a situation where a patient's temperature is dropping below the normal range during surgery, the nurse should prioritize actively warming the patient to prevent hypothermia. Administering a warming blanket or using a forced-air warming device are effective methods to increase the patient's body temperature and prevent any complications that may arise from hypothermia. Increasing the ambient room temperature can help, but it may not be as direct or effective as applying targeted heat sources to the patient. Documenting the temperature trend in the patient's chart is important for record-keeping purposes, but immediate action to address the dropping temperature is necessary. Continuously monitoring the patient's temperature closely is important, but action should be taken promptly to prevent further decline.