Adult Health Nursing Test Banks

Correct Answer: A

Rationale: An occiput posterior fetal position, where the baby's head is facing the mother's abdomen rather than her back, can lead to prolonged and severe back pain during labor. This position can cause irregular contractions and difficulty in descending through the birth canal, resulting in abnormal labor progress. The back pain experienced in this case is often intense due to the pressure exerted on the mother's lower back and may also be associated with intense back labor. It is essential for the nurse to recognize this potential issue and assist in maneuvers or positions to help the baby rotate to a more optimal position for delivery.

Correct Answer: C

Rationale: The indicators listed indicate measures that Nurse Cirila can take to maintain a safe environment for her pediatric patients. However, assessing the competencies of staff before delegating a task is more related to ensuring effective delegation and appropriate task assignment rather than directly ensuring a safe environment for patients. While it is important to delegate tasks to qualified staff, this specific action does not directly contribute to maintaining a safe environment in the same manner as the other indicators listed (proper waste disposal, infection control, emergency protocols).

Correct Answer: C

Rationale: The most effective strategy in preventing more incidence of dengue infection is to target the breeding places of the Aedes mosquitoes, which are the vectors responsible for transmitting the dengue virus. By eliminating stagnant water sources where these mosquitoes breed, such as uncovered containers, flower pots, and discarded tires, the mosquito population can be significantly reduced. This, in turn, helps to lower the risk of dengue transmission to humans. While healthy nutritious food, burning of leaves and garbage, and adequate rest and sleep are important for overall health and immune function, they do not directly address the primary cause of dengue transmission, which is the Aedes mosquito population.

Correct Answer: B

Rationale: In an educational program conducted by a nurse, it is crucial to involve the patient, their family, and significant others. This approach ensures holistic care by considering the patient's psychosocial environment, family dynamics, and support system. Including these individuals in the educational program fosters collaboration, strengthens the patient-nurse relationship, and equips family members with the knowledge and skills needed to provide optimal care at home. Furthermore, involving the patient's support system can enhance adherence to treatment plans and contribute to better health outcomes. Therefore, the presence and cooperation of the patient, family, and significant others are essential elements of a successful educational program led by a nurse.

Correct Answer: B

Rationale: The clinical scenario described is consistent with a diagnosis of anterior epistaxis due to a prominent vascular lesion located in Little's area, which is an important site for nosebleeds. Silver nitrate cautery is the most appropriate intervention for managing this condition. Silver nitrate cautery is a commonly used method to chemically cauterize and eliminate the friable blood vessels responsible for recurrent epistaxis. It is a cost-effective and minimally invasive technique that can be easily performed in an outpatient setting. Nasal packing with anterior nasal tampons might be considered in cases of severe or refractory epistaxis, but in this scenario, where the source of bleeding is localized and identifiable, silver nitrate cautery is the treatment of choice. Endoscopic cauterization of the sphenopalatine artery and surgical excision of a nasal polyp are unnecessary and overly invasive for the described scenario.