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: Myxedema is a severe form of hypothyroidism that is characterized by the accumulation of mucopolysaccharides in subcutaneous and other interstitial tissues. This condition leads to puffiness, swelling, and thickening of the skin, giving it a waxy appearance. Other symptoms of myxedema include fatigue, weight gain, cold intolerance, and hair loss. It is important to recognize and treat myxedema promptly as it can lead to serious complications such as myxedema coma, which is a life-threatening condition requiring immediate medical attention.

Correct Answer: B

Rationale: The nurse can assure Sandy that her new joint will function almost as well as a normal joint if she performs her exercises faithfully because post-joint replacement surgery recovery often involves physical therapy and exercises aimed at restoring strength and mobility to the affected joint. By following the recommended exercise regimen and post-operative care instructions, Sandy can improve the function of her new joint and achieve a good level of mobility and functionality, similar to that of a normal joint. It is important for Sandy to be diligent and committed to her rehabilitation process to maximize the benefits of the joint replacement surgery.

Correct Answer: D

Rationale: When a woman in active labor demonstrates signs of cephalopelvic disproportion (CPD) with the fetal head failing to descend despite strong contractions, the nursing action that should be prioritized is to prepare for immediate instrumental delivery. CPD can lead to a prolonged and difficult labor, increasing the risks for both the mother and the fetus. In cases where the fetal head is not descending adequately and the mother's contractions are strong, instrumental delivery, like forceps or vacuum extraction, may be necessary to facilitate the safe delivery of the baby. It is important to act promptly to avoid potential complications associated with prolonged labor. Other actions, such as performing a pelvic exam, changing maternal positions, or administering oxytocin, may be considered but addressing the issue of CPD efficiently through instrumental delivery should take precedence in this scenario.

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.