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: 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.

Correct Answer: D

Rationale: When a postpartum client exhibits signs of postpartum psychosis such as hallucinations, delusions, and disorganized behavior, it is crucial to involve the healthcare provider immediately. Postpartum psychosis is a psychiatric emergency that requires prompt assessment and intervention by mental health professionals. The healthcare provider can determine the appropriate course of action, which may include hospitalization, medication management, and specialized psychiatric care. Delaying notification can lead to serious consequences for both the client and her infant, so timely intervention is essential in managing postpartum psychosis.

Correct Answer: B

Rationale: Nurses are bound by strict confidentiality and privacy regulations in their profession. If a nurse fails to keep a patient's personal information confidential and discloses it without authorization, they can be charged with invasion of privacy. Invasion of privacy is the wrongful intrusion into a person's private affairs without their consent, and it is a serious violation of ethical and legal standards in healthcare. Nurses must always prioritize patient confidentiality to maintain trust and uphold ethical standards in their practice.

Correct Answer: A

Rationale: Demonstrating tandem breastfeeding positions and techniques should be prioritized as the nursing intervention to address the client's concerns about breastfeeding both infants simultaneously. Tandem breastfeeding involves nursing twins at the same time and can help enhance milk production, promote bonding with both infants, and save time for the mother. By showing the client the proper positions and techniques for tandem breastfeeding, the nurse can empower the client with the knowledge and skills needed to successfully breastfeed both infants together. This intervention can ultimately support the client in feeling more confident and competent in managing the challenges of breastfeeding twins.