Adult Health Med Surg Nursing Test Banks

Correct Answer: A

Rationale: In the scenario described, the patient was considered an emergency case upon referral to the tertiary hospital. Since a specialist was immediately called for by the nurse, the most likely specialist needed in an emergency situation is a neurologist. Neurologists are physicians who specialize in diagnosing and treating disorders of the nervous system, including the brain, spinal cord, and nerves. In an emergency case where a patient's neurological condition needs urgent attention, a neurologist would be the most appropriate specialist to address the situation promptly and effectively.

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.

Correct Answer: C

Rationale: Pituitary adenoma is the most likely neurological condition responsible for the described symptoms of acute onset severe headache, visual disturbances, and altered mental status when a tumor is found compressing the optic chiasm. Pituitary adenomas are benign tumors arising from the pituitary gland located at the base of the brain. As the tumor grows, it can compress nearby structures such as the optic chiasm, leading to visual disturbances (due to pressure on the optic nerves), severe headache (due to increased intracranial pressure), and altered mental status (due to effects on nearby brain structures).

Correct Answer: C

Rationale: The presentation described is most consistent with a thyroid adenoma. Thyroid adenomas are benign neoplasms of the thyroid gland and can present as painless, gradually enlarging masses in the neck. Fine-needle aspiration cytology revealing thyroid follicular cells further supports the diagnosis of a thyroid adenoma. Thyroglossal duct cysts typically present as midline neck masses that move with swallowing, while lymphadenopathy presents as enlarged lymph nodes and may be associated with infection or malignancy. Thyroid carcinoma may also present as a neck mass but is more likely to be associated with other features such as vocal cord paralysis, hoarseness, or enlarged cervical lymph nodes.

Correct Answer: A

Rationale: Atopic dermatitis is a chronic, pruritic inflammatory skin condition that typically presents in individuals with a personal or family history of asthma and allergic rhinitis (hay fever). The characteristic presentation includes erythematous papules, vesicles, and excoriations on the flexural surfaces of the elbows and knees. This type of dermatitis is commonly seen in patients with atopy, which refers to a genetic predisposition to develop allergic diseases like asthma, hay fever, and eczema. Therefore, given the patient's personal history of asthma and hay fever along with the described rash distribution and appearance, atopic dermatitis is the most likely diagnosis.