Adult Health Med Surg Nursing Test Banks

Correct Answer: A

Rationale: Nicotine, a substance found in cigarettes, is known to have harmful effects on pregnancy. Smoking during pregnancy can lead to numerous complications, one of which is the increased risk of delivering a low birth weight infant. Low birth weight infants are born weighing less than 5.5 pounds (2.5 kilograms) and are at a higher risk of various health issues, developmental delays, and even mortality. Therefore, Nurse Emma advised the patient to quit smoking to reduce the risk of having a low birth weight infant.

Correct Answer: B

Rationale: Hip dysplasia is a common complication associated with untreated clubfoot in infants. If clubfoot is not treated promptly and properly, it can lead to abnormal development of the hip joint, resulting in hip dysplasia. This condition involves the abnormal formation of the hip socket, which can cause instability and potential dislocation of the hip joint. Early identification and treatment of clubfoot are important in preventing complications such as hip dysplasia.

Correct Answer: A

Rationale: The behavior of repetitive cleaning in someone diagnosed with obsessive-compulsive disorder is likely an attempt to decrease the anxiety to a tolerable level. People with OCD often engage in compulsive behaviors, such as cleaning, in an effort to alleviate the distress and anxiety caused by obsessive thoughts. This repetitive action provides a sense of control and temporary relief from the anxiety associated with their obsessive thoughts. By engaging in cleaning rituals, individuals with OCD can try to reduce their anxious feelings and create a sense of order and cleanliness in their environment.

Correct Answer: C

Rationale: The correct information that the incoming nurse should chart is that she received 800 cc of IV fluid. It is crucial for the charting to accurately reflect the actual situation to provide an accurate record for the patient's care. In this scenario, the discrepancy between the endorsed amount (400 cc) and the observed amount (800 cc) should be documented to ensure transparency and continuity of care. This deviation from the expected amount should be clearly recorded for proper monitoring and evaluation of the patient's condition.

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.