Adult Health Med Surg Nursing Test Banks

Correct Answer: D

Rationale: Choosing option D, "Donato, what you are saying is inappropriate," is the most appropriate response in this situation. It directly addresses Nurse Donato's behavior without escalating the situation or being overly confrontational. By calmly pointing out that the remarks are inappropriate, you are setting a boundary and letting Nurse Donato know that such behavior is not acceptable in a professional setting. This response also signals to the rest of the group that you are aware of the inappropriate comments and are taking action to address them. It is important to address such behavior professionally and assertively to maintain a respectful and supportive environment during the support group meeting.

Correct Answer: B

Rationale: A temperature of 39.8 degrees Celsius (103.6 degrees Fahrenheit) in a patient following abdominal surgery and ongoing blood transfusion may indicate an ongoing potential infection. During surgery, the body is exposed to various microorganisms, and the stress of surgery can weaken the immune system, making the patient more susceptible to infections. Blood transfusions also carry a risk of introducing infections if not properly screened. Therefore, in this situation, an elevated temperature may be a sign that an infection is developing, and prompt notification of the surgeon is important for further evaluation and management.

Correct Answer: D

Rationale: The prioritized nursing intervention in this situation should be assessing for the risk of harm to self or infant. It is crucial to ensure the safety of the postpartum client and her infant as depression can increase the risk of self-harm or harm to the newborn. By assessing for any potential risks, the nurse can take appropriate actions to prevent any harm and ensure the well-being of both the client and the infant. Once the assessment is completed, further interventions like encouraging participation in support groups, referring to a mental health professional, or administering medications can be considered based on the assessment findings.

Correct Answer: D

Rationale: The assessment finding that is indicative of the diagnosis of hypertension is consistent evaluation of blood pressure. Hypertension is diagnosed based on repeated measurements of elevated blood pressure. Consistently high blood pressure readings, usually defined as systolic blood pressure consistently at or above 140 mmHg and diastolic blood pressure consistently at or above 90 mmHg, are a key factor in diagnosing hypertension. Family history of high blood pressure (Choice A), elevation of blood cholesterol level (Choice B), and a stressful work environment (Choice C) may be risk factors for hypertension but are not diagnostic criteria. In order to diagnose hypertension, healthcare providers rely on consistent measurement and evaluation of blood pressure over time.

Correct Answer: C

Rationale: Prostatitis is characterized by inflammation of the prostate gland, leading to symptoms such as dysuria (painful urination), urinary frequency, urinary urgency, and perineal or pelvic pain. Prostate cancer, on the other hand, is characterized by the presence of malignant cells in the prostate gland and may not present with these typical symptoms. Benign prostatic hyperplasia (BPH) is a non-cancerous enlargement of the prostate gland that can cause urinary symptoms but is not typically associated with inflammation. Urethritis refers to inflammation of the urethra, which is a different condition and may present with symptoms such as painful urination and discharge from the urethra.