Adult Health Med Surg Nursing Test Banks

Correct Answer: B

Rationale: The nurse can assure Sandy that her new joint will function almost as well as a normal joint if she performs her exercises faithfully because post-joint replacement surgery recovery often involves physical therapy and exercises aimed at restoring strength and mobility to the affected joint. By following the recommended exercise regimen and post-operative care instructions, Sandy can improve the function of her new joint and achieve a good level of mobility and functionality, similar to that of a normal joint. It is important for Sandy to be diligent and committed to her rehabilitation process to maximize the benefits of the joint replacement surgery.

Correct Answer: B

Rationale: The nurse should prioritize cleansing the insertion site with an alcohol-based antiseptic solution to maintain procedural asepsis during a peripherally inserted central catheter (PICC) insertion. Proper skin preparation is essential in reducing the risk of introducing pathogens into the patient's bloodstream during the insertion process. Alcohol-based antiseptic solutions are effective in reducing the number of microorganisms on the skin surface. Wearing sterile gloves and following other sterile techniques are also crucial, but preparing the insertion site with the antiseptic solution is the initial step in maintaining asepsis during the procedure.

Correct Answer: B

Rationale: The symptoms described—tachycardia, weight loss, and tremors—are consistent with hyperthyroidism. Graves' disease is the most common cause of hyperthyroidism and is an autoimmune disorder in which the thyroid gland is overactive. This condition can lead to an increased production of thyroid hormones, resulting in symptoms such as rapid heartbeat (tachycardia), unintended weight loss, and tremors. In contrast, Hashimoto's thyroiditis is an autoimmune disorder that causes hypothyroidism, leading to symptoms like fatigue, weight gain, and cold intolerance. Diabetes mellitus is a metabolic disorder characterized by high blood sugar levels, which typically presents with symptoms such as increased thirst, frequent urination, and fatigue. Thyroid nodules are growths within the thyroid gland that can sometimes be associated with overactive (hyperthyroidism) or underactive (hypothyroidism) thyroid function, but they do not

Correct Answer: B

Rationale: Uterine hyperstimulation is a condition in which the uterus contracts too frequently or too intensely, leading to decreased blood flow and oxygenation to the placenta. This can result in maternal fatigue and decreased fetal oxygenation due to the lack of sufficient rest intervals between contractions. Uterine hyperstimulation can be caused by factors such as the use of synthetic oxytocin (Pitocin) to induce or augment labor, uterine abnormalities, or maternal conditions like pre-eclampsia. It is important for the nurse to assess for uterine hyperstimulation in a woman experiencing frequent and intense contractions to intervene promptly and prevent adverse outcomes for both the mother and the baby.

Correct Answer: B

Rationale: The patient is presenting with symptoms consistent with cluster headache. Cluster headaches are characterized by recurrent episodes of severe unilateral (ipsilateral) headache accompanied by lacrimation (tearing from the eyes), rhinorrhea (runny nose), and ptosis (drooping of the eyelid). These headaches often occur in clusters over a period of weeks to months, hence the name "cluster headache."