Adult Health Med Surg Nursing Test Banks

Correct Answer: D

Rationale: When a woman in active labor demonstrates signs of cephalopelvic disproportion (CPD) with the fetal head failing to descend despite strong contractions, the nursing action that should be prioritized is to prepare for immediate instrumental delivery. CPD can lead to a prolonged and difficult labor, increasing the risks for both the mother and the fetus. In cases where the fetal head is not descending adequately and the mother's contractions are strong, instrumental delivery, like forceps or vacuum extraction, may be necessary to facilitate the safe delivery of the baby. It is important to act promptly to avoid potential complications associated with prolonged labor. Other actions, such as performing a pelvic exam, changing maternal positions, or administering oxytocin, may be considered but addressing the issue of CPD efficiently through instrumental delivery should take precedence in this scenario.

Correct Answer: A

Rationale: Wearing a mask is an essential infection control measure to prevent the spread of respiratory illnesses, including COVID-19. By wearing a mask, Nurse Emma can reduce the risk of inhaling or exhaling respiratory droplets that may contain infectious particles, thus helping to protect herself and the family members she is visiting. Masks are particularly crucial when interacting with individuals who are sick or when physical distancing may be challenging. While using gloves, face shields, and gowns are also important infection control measures in certain situations, wearing a mask is the most relevant and effective measure during a home visit to prevent respiratory transmission of infections.

Correct Answer: D

Rationale: A trimalleolar fracture is characterized by fractures involving the lateral malleolus (distal fibula), medial malleolus (distal tibia), and the posterior tubercle of the distal tibia. This fracture pattern results in instability of the ankle joint and is often associated with widening of the ankle mortise on X-ray. The deformity and swelling seen in this patient are indicative of a trimalleolar fracture and are typically caused by a high-energy injury, such as a forceful twisting motion. Treatment for trimalleolar fractures often involves surgical intervention to stabilize the ankle joint and restore normal function.

Correct Answer: D

Rationale: Incompetent cervix refers to a weakened cervix that is unable to support the weight of the growing fetus, leading to painless cervical dilation and second-trimester pregnancy loss. In this condition, the cervix may dilate prematurely without contractions, resulting in a painless cervical dilation. The history of recurrent second-trimester losses, along with cervical dilation and absence of uterine contractions in the presenting pregnant woman, are characteristic of incompetent cervix. Prompt recognition and management with cerclage placement can help prevent further pregnancy losses in women with incompetent cervix.

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.