Adult Health Nursing Test Banks

Correct Answer: C

Rationale: The barrier to goal setting between the nurse and the family in this scenario is the failure of the family to perceive the existence of the problem. Goal setting in healthcare generally requires mutual agreement and understanding between the healthcare provider (nurse) and the patient/family. If the family does not perceive that there is an existing problem that needs to be addressed, there will likely be resistance or lack of motivation to set goals and work towards resolving the issue. This barrier can hinder effective communication, collaboration, and ultimately, the successful achievement of healthcare goals. It is important for the nurse to address this barrier through education, communication, and building trust to ensure that all parties are on the same page and actively participate in goal setting and care planning.

Correct Answer: B

Rationale: Mood swings are recognized as a typical part of a normal pregnancy due to the hormonal changes that occur. Pregnant individuals may experience a wide range of emotions, from joy and elation to frustration and irritability. These fluctuations in mood are considered normal and not necessarily indicative of a more serious issue. It is essential for pregnant women to receive support and understanding during this time as they navigate the emotional ups and downs of pregnancy. Feelings being easily hurt by remarks (A) and narcissism (D) are not typically accepted as part of a normal pregnancy and may require further attention or support. While finding a situation amusing or charming (C) can be a positive experience, it is not specifically indicative of a normal emotional reaction during pregnancy.

Correct Answer: A

Rationale: The described presentation is classic for acute angle-closure glaucoma. This condition is characterized by sudden-onset severe eye pain, headache, nausea, and vomiting. The red eye, steamy cornea (corneal edema), and mid-dilated non-reactive pupil are consistent with acute angle-closure glaucoma. The sudden increase in intraocular pressure leads to impaired aqueous humor outflow, causing these symptoms. Immediate intervention is required to prevent permanent vision loss in such cases. Central retinal artery occlusion would present with sudden painless vision loss. Optic neuritis typically presents with vision loss and pain with eye movements. Corneal ulcer presents with eye discomfort, foreign body sensation, and may have a history of corneal trauma or contact lens wear.

Correct Answer: A

Rationale: The patient's presentation of episodic throbbing headache associated with nausea, vomiting, sensitivity to light and sound, and aura suggests a diagnosis of migraine headache. Migraines are a common neurological condition characterized by recurrent moderate to severe headaches that are often unilateral, pulsating, and aggravated by physical activity. The presence of premonitory symptoms (aura) before the headache is a key feature commonly seen in migraines. Additionally, nausea, vomiting, and sensitivity to light and sound are also common features associated with migraines.

Correct Answer: B

Rationale: The presentation of a patient with diabetes mellitus showing symptoms of polyuria, polydipsia, nocturia, and fatigue along with laboratory findings of hyperglycemia, glycosuria, and ketonuria is indicative of diabetic ketoacidosis (DKA). DKA is a serious complication of diabetes characterized by hyperglycemia, metabolic acidosis, and ketosis. The increased glucose levels lead to glycosuria, causing osmotic diuresis resulting in polyuria, polydipsia, and nocturia. The body starts breaking down fats for energy in the absence of sufficient insulin, leading to the production of ketones causing ketonuria. The patient may also experience fatigue due to the metabolic abnormalities present in DKA.