Adult Health Med Surg Nursing Test Banks

Correct Answer: A

Rationale: When a baby is placed on phototherapy, especially for treating jaundice, it is crucial for the nurses to put sunglasses on the newborn to protect their eyes. Phototherapy involves exposing the baby's skin to certain types of light to help break down the bilirubin causing the jaundice. However, this light can be harmful to the baby's sensitive eyes, potentially leading to eye damage or other eye-related issues if not protected adequately. Therefore, placing sunglasses on the newborn is a necessary precaution to ensure the safety and well-being of the baby's eyes during the treatment.

Correct Answer: A

Rationale: Urinary tract infections are strongly associated with the occurrence of preterm labor. It is important to screen for and address any urinary tract infections during pregnancy to reduce the risk of complications like preterm labor. Diagnostic procedures, such as obtaining a urine sample for testing, help healthcare providers identify and treat any infections promptly to promote a healthy pregnancy. Therefore, the nurse can explain to Patient Presley that the diagnostic procedure is necessary to detect and address any potential urinary tract infections that could impact her pregnancy.

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: C

Rationale: The central theme of Sr. Callista Roy's theory is adaptation. Roy's Adaptation Model focuses on the individual's ability to adapt to internal and external stimuli in order to maintain health and well-being. The theory emphasizes the interconnectedness of the individual and their environment, highlighting the dynamic process of adaptation in response to stimuli. By focusing on adaptation, Roy's theory guides nursing practice in promoting holistic care that supports individuals in adapting to changes and achieving optimal health outcomes.

Correct Answer: B

Rationale: The clinical presentation of lower abdominal pain, dyspareunia (pain during sexual intercourse), dysmenorrhea (painful periods), and tender nodules along the uterosacral ligaments is highly suggestive of endometriosis. Endometriosis is a condition where the tissue that lines the uterus (endometrium) grows outside the uterus, commonly on the pelvic organs such as the ovaries, fallopian tubes, and the peritoneum. The characteristic tender nodules along the uterosacral ligaments are known as "nodularity" and are a classic finding in endometriosis.