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: A

Rationale: Opsonization refers to the process by which antibodies bind to the surface of pathogens, marking them for destruction by phagocytes or complement proteins. This coating of antibodies enhances the ability of the immune system to recognize and eliminate the pathogens effectively. Phagocytes (such as macrophages and neutrophils) are better able to engulf and digest pathogens that have been opsonized, as the antibodies attached to the pathogen surface signal to the phagocytes that they are foreign invaders. This process is crucial in the body's immune response to infections and helps in clearing pathogens from the system.

Correct Answer: B

Rationale: Documenting all care provided, including assessments and interventions, is the principle that should guide the nurse's documentation practices in the electronic health record (EHR). Comprehensive and accurate documentation is essential for ensuring continuity of care, communication among healthcare team members, and legal protection. By documenting all care provided, the nurse contributes to a complete and thorough picture of the patient's condition and treatment, facilitating safe and effective patient care. This principle also aligns with professional standards and regulatory requirements, emphasizing the importance of timely and complete documentation in the EHR.

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: C

Rationale: It is essential for the nurse to document important observations made during a tracheostomy procedure, and this includes the amount, color, and consistency of sputum as well as the appearance of the incision. Monitoring these factors helps assess the patient's respiratory status, risk of infection, and wound healing progress. Ensuring detailed documentation in this area allows for timely intervention if there are any concerning changes observed post-procedure. Observations such as the response of the patient, vital signs during the procedure, and patient behavior are also important but may be documented separately from the specific details related to sputum, incision appearance, and wound care.