Adult Health Med Surg Nursing Test Banks

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: B

Rationale: Ectopic pregnancy is a common complication of untreated gonorrhea or chlamydia infection in women. This occurs when a fertilized egg implants and grows outside the uterus, typically in one of the fallopian tubes. Both gonorrhea and chlamydia can lead to scarring of the fallopian tubes due to untreated inflammation and infection. This scarring may obstruct the fallopian tubes, making it difficult for the fertilized egg to travel to the uterus for implantation. As a result, the egg may implant and grow in the fallopian tube, leading to an ectopic pregnancy. Ectopic pregnancies are dangerous and can result in serious complications for the woman, including rupture of the fallopian tube, internal bleeding, and potentially life-threatening situations. It is crucial to seek prompt treatment for gonorrhea and chlamydia to prevent such severe outcomes.

Correct Answer: B

Rationale: The severe abdominal cramps experienced by the multiparous patient Amy, 28 hours after a Cesarean delivery (CS) and while breastfeeding, are likely caused by the release of Oxytocin during the breastfeeding session. Oxytocin is a hormone that is naturally produced during breastfeeding to stimulate the contraction of the uterus and help reduce postpartum bleeding. These contractions may result in cramping sensations in the abdomen, specifically at the site of the uterus. It is a normal physiological response and an indication that the body is working as it should to support the postpartum recovery process.

Correct Answer: B

Rationale: The pharynx is the structure responsible for transporting food from the oral cavity to the esophagus during swallowing. When food is chewed and mixed with saliva in the oral cavity, it forms a bolus that is propelled to the pharynx by the tongue. The pharynx serves as a common passageway for both air and food, allowing the bolus to pass into the esophagus while preventing it from entering the trachea. The epiglottis, although important in preventing food from entering the airway, is not directly involved in the transportation of food from the oral cavity to the esophagus.

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.