Adult Health Med Surg Nursing Test Banks

Correct Answer: C

Rationale: In response to chronic hypoxia, the body adapts to increase oxygen delivery to tissues by increasing cardiac output. This is achieved by increasing the heart rate and stroke volume, allowing more oxygenated blood to be pumped to the tissues. The increased cardiac output helps compensate for the lower oxygen levels in the blood, ensuring that tissues receive an adequate supply of oxygen despite the hypoxic conditions. This physiological adaptation is essential for maintaining tissue oxygenation and supporting overall cellular function in the presence of chronic hypoxia.

Correct Answer: A

Rationale: The priority intervention in managing acute pancreatitis is to administer intravenous fluids to maintain adequate hydration. Acute pancreatitis can lead to significant fluid loss and dehydration due to factors such as vomiting and third-spacing of fluids into the retroperitoneal space. Adequate hydration helps to optimize perfusion to the pancreas, prevent hypovolemic shock, and support overall organ function. This intervention also aids in flushing out inflammatory mediators and preventing complications such as acute kidney injury. Monitoring fluid status and adjusting the rate of intravenous fluid administration based on the patient's response is crucial in the management of acute pancreatitis. While other interventions such as imaging studies, nutritional support, and gastric acid suppression may be important in managing acute pancreatitis, ensuring adequate hydration is the most critical initial step.

Correct Answer: A

Rationale: For a patient diagnosed with a hemorrhagic stroke, the caregiver should ensure that the bed is positioned in a High-Fowler's position. This position involves elevating the head of the bed between 60 to 90 degrees. Elevating the head of the bed helps to reduce intracranial pressure and promote optimal cerebral perfusion. It also assists in maintaining proper ventilation and oxygenation, which are essential for the patient's recovery. It is important to avoid positioning the patient flat or in a prone position as these may exacerbate the condition and lead to further complications.

Correct Answer: A

Rationale: Turning and repositioning the patient every 2 hours is the most effective nursing intervention in preventing pressure ulcers in a patient with a history of stroke and immobility. Pressure ulcers, also known as bedsores, are caused by prolonged pressure on the skin, leading to reduced blood flow and tissue damage. By regularly turning and repositioning the patient, pressure is relieved from specific areas of the body, helping to prevent the development of pressure ulcers. This intervention helps to redistribute pressure, improve blood flow, and reduce the risk of skin breakdown, thus promoting skin integrity in immobile patients.

Correct Answer: A

Rationale: Endometriosis is the most likely condition responsible for the symptoms described in this scenario. Endometriosis is a chronic condition in which endometrial-like tissue grows outside the uterus, commonly affecting the pelvic structures such as the ovaries, fallopian tubes, and pelvic peritoneum. The main symptoms include cyclic pelvic pain, dysmenorrhea (painful periods), and dyspareunia (pain during intercourse). The retroverted and fixed uterus on examination may be due to adhesions from endometriosis, causing the uterus to be fixed in position. Endometriosis should be considered in women of reproductive age presenting with these symptoms and pelvic examination findings.