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: D

Rationale: While urinalysis can provide valuable information about a person's health status and can be part of a clinical assessment, it is not typically considered a common screening test for specific diseases or conditions. The other options listed - Pap smears for cervical cancer screening, cholesterol levels for heart disease screening, and PSA levels for prostate cancer screening - are all commonly used screening tests aimed at early detection of specific diseases. Urinalysis is more commonly used as part of a broader health assessment or diagnostic evaluation rather than a dedicated screening tool for a specific condition.

Correct Answer: D

Rationale: A trimalleolar fracture is characterized by fractures involving the lateral malleolus (distal fibula), medial malleolus (distal tibia), and the posterior tubercle of the distal tibia. This fracture pattern results in instability of the ankle joint and is often associated with widening of the ankle mortise on X-ray. The deformity and swelling seen in this patient are indicative of a trimalleolar fracture and are typically caused by a high-energy injury, such as a forceful twisting motion. Treatment for trimalleolar fractures often involves surgical intervention to stabilize the ankle joint and restore normal function.

Correct Answer: A

Rationale: The most significant contributory factor to the development of lung cancer is being a cigarette smoker. Cigarette smoking is directly linked to approximately 85% of lung cancer cases. The harmful substances in tobacco smoke, such as carcinogens, damage the cells in the lungs, leading to the development of cancer over time. Smokers are at a significantly higher risk of developing lung cancer compared to non-smokers. Therefore, being a cigarette smoker is the primary and most influential risk factor for developing lung cancer.

Correct Answer: D

Rationale: Thrombocytopenia is a condition characterized by a low platelet count, which can lead to an increased risk of bleeding. Patients with thrombocytopenia are at risk for injury due to potential bleeding complications. Therefore, the appropriate nursing diagnosis to protect the patient from further injury in this case would be "Risk for injury related to thrombocytopenia." This nursing diagnosis allows the nurse to assess for signs of bleeding, implement interventions to prevent injury, and closely monitor the patient's platelet levels to prevent complications.