Adult Health Med Surg Nursing Test Banks

Correct Answer: B

Rationale: When a patient describes their pain as a 5 on the pain assessment scale, it indicates severe pain and the need for a strong pain medication. Morphine Sulphate is a potent opioid analgesic that is commonly used to manage severe pain, such as in cases where the pain is rated as 5. Meperidine HCl (Demerol) is another opioid analgesic, but it is not as commonly used due to its side effect profile and potential for toxicity. Fentanyl (Duragesic) is also a potent opioid analgesic that can be used for severe pain, but morphine is often preferred in this situation. Acetaminophen (Tylenol) is a milder pain reliever and is not typically sufficient for pain described at a level of 5 on the pain scale.

Correct Answer: B

Rationale: The right to refuse treatment is a fundamental patient right. In this case, the physician ordering medications for the client to take at home without the client's input or agreement could possibly violate the client's right to refuse treatment. It is important for patients to have the autonomy to make decisions regarding their own treatment, especially when they are still weak and symptomatic. Patients should have the opportunity to discuss their treatment plan with their healthcare provider and express any concerns or preferences they may have.

Correct Answer: A

Rationale: The patient's presentation of recurrent episodes of sudden, severe vertigo lasting hours with nausea, vomiting, and nystagmus, along with unilateral weakness on vestibular function tests, is most consistent with vestibular neuritis. Vestibular neuritis is characterized by inflammation of the vestibular nerve leading to sudden onset vertigo that can last for hours to days. It is often associated with nausea, vomiting, and nystagmus. Unilateral weakness on vestibular function tests indicates dysfunction of one vestibular system. Differential diagnosis for this type of presentation includes other conditions such as Meniere's disease, BPPV, and acoustic neuroma. However, the combination of symptoms and unilateral vestibular weakness makes vestibular neuritis the most likely diagnosis in this case.

Correct Answer: C

Rationale: Children with ADHD often display hyperactive and impulsive behaviors, such as excessive running, climbing, and fidgeting. These behaviors are characteristic symptoms of the hyperactive-impulsive subtype of ADHD. Children with ADHD may struggle to sit still, have difficulty engaging in quiet activities, and often seem on the go. Therefore, the nurse would expect to see signs of excessive movement and restlessness in a child with ADHD.

Correct Answer: D

Rationale: The ethical principle of beneficence, which is the basis of every nursing action in all work settings, emphasizes the importance of doing good at all times for the benefit of the patient. Nurses are expected to act in the best interest of their patients and strive to promote their well-being and welfare. This principle guides nurses to provide care that is compassionate, effective, and in line with the patient's needs and preferences. By prioritizing the good of the patient in all actions and decisions, nurses uphold the principle of beneficence and demonstrate their commitment to promoting positive outcomes for those under their care.