Adult Health Med Surg Nursing Test Banks

Correct Answer: B

Rationale: Nursing interventions should be aimed at addressing the mother's needs for psychological security. Hyper vigilance and excessive worry about her child's safety indicate a lack of security in her mind. By providing support, reassurance, and education, nurses can help the mother feel more secure in her role as a parent and reduce her feelings of anxiety and distress. Establishing trust and building a therapeutic relationship can also contribute to enhancing the mother's psychological security and well-being.

Correct Answer: A

Rationale: Rehabilitation prior to discharge is best described as a period of ups and downs, physically and emotionally because it involves the recovery process after an illness, injury, or medical procedure. It is a challenging time where the patient may experience setbacks and improvements on their journey back to health. There can be physical challenges such as regaining strength and mobility, as well as emotional challenges like coping with the changes in their condition. Therefore, the rehabilitation process is often not smooth and can be a rollercoaster of progress and setbacks, both physically and emotionally.

Correct Answer: B

Rationale: The nurse should prioritize cleansing the insertion site with an alcohol-based antiseptic solution to maintain procedural asepsis during a peripherally inserted central catheter (PICC) insertion. Proper skin preparation is essential in reducing the risk of introducing pathogens into the patient's bloodstream during the insertion process. Alcohol-based antiseptic solutions are effective in reducing the number of microorganisms on the skin surface. Wearing sterile gloves and following other sterile techniques are also crucial, but preparing the insertion site with the antiseptic solution is the initial step in maintaining asepsis during the procedure.

Correct Answer: B

Rationale: Hip dysplasia is a common complication associated with untreated clubfoot in infants. If clubfoot is not treated promptly and properly, it can lead to abnormal development of the hip joint, resulting in hip dysplasia. This condition involves the abnormal formation of the hip socket, which can cause instability and potential dislocation of the hip joint. Early identification and treatment of clubfoot are important in preventing complications such as hip dysplasia.

Correct Answer: A

Rationale: In a patient with severe abdominal pain due to end-stage pancreatic cancer, the priority intervention to manage their symptoms would be to provide adequate pain relief. Opioid analgesics are the cornerstone of pain management for cancer patients experiencing severe pain. They work by binding to opioid receptors in the central nervous system, thereby reducing the perception of pain. Opioids are highly effective in managing cancer pain, including abdominal pain, and can significantly improve the patient's quality of life by providing relief from distressing symptoms. Therefore, administering opioid analgesics should be the nurse's primary intervention in this case to address the patient's severe abdominal pain. Initiating enteral nutrition, recommending hot compresses, or referring to a gastroenterologist may be relevant interventions depending on the patient's overall care plan but addressing the pain should be the immediate priority in this scenario.