Adult Health Med Surg Nursing Test Banks

Correct Answer: C

Rationale: A living will is a legal document that outlines a person's preferences and wishes regarding medical treatment, including resuscitation, in the event they become unable to communicate or make decisions. In this scenario, the client being admitted to the oncology unit wants to convey his wishes regarding resuscitation in case of cardiopulmonary arrest. A living will helps ensure that these wishes are known and respected by healthcare providers and loved ones. While a will addresses how a person's assets should be distributed after death and a health care power of attorney designates someone to make medical decisions on the person's behalf, a living will specifically focuses on healthcare preferences and treatment decisions. A proxy directive is similar to a health care power of attorney, designating someone to make healthcare decisions for the person if they are unable to do so themselves.

Correct Answer: A

Rationale: The PRIORITY nursing action when receiving information about suspected child abuse is to report to the police authorities. Child abuse is a serious issue that requires immediate intervention to ensure the safety and well-being of the child. The police are trained to investigate these types of situations and can take the necessary steps to protect the child from harm. It is essential to act swiftly and report any suspicions of child abuse to the proper authorities to prevent further harm and ensure the child's safety.

Correct Answer: B

Rationale: When a patient arrives in the emergency room, the nurse's first priority is to assess the patient's airway, breathing, and circulation, following the ABCs of emergency care. In this scenario, positioning the patient with the head lower than the extremities ensures proper blood flow to vital organs, especially the brain. This position helps to maintain perfusion to the brain and prevent complications such as hypotension and shock. Once the patient's position is optimized, the nurse can proceed with further interventions such as starting an intravenous line, stopping bleeding, and requesting laboratory examinations as needed.

Correct Answer: A

Rationale: In a patient with severe abdominal pain due to end-stage pancreatic cancer, the priority intervention to manage their symptoms would be to provide adequate pain relief. Opioid analgesics are the cornerstone of pain management for cancer patients experiencing severe pain. They work by binding to opioid receptors in the central nervous system, thereby reducing the perception of pain. Opioids are highly effective in managing cancer pain, including abdominal pain, and can significantly improve the patient's quality of life by providing relief from distressing symptoms. Therefore, administering opioid analgesics should be the nurse's primary intervention in this case to address the patient's severe abdominal pain. Initiating enteral nutrition, recommending hot compresses, or referring to a gastroenterologist may be relevant interventions depending on the patient's overall care plan but addressing the pain should be the immediate priority in this scenario.

Correct Answer: C

Rationale: Pituitary adenoma is the most likely neurological condition responsible for the described symptoms of acute onset severe headache, visual disturbances, and altered mental status when a tumor is found compressing the optic chiasm. Pituitary adenomas are benign tumors arising from the pituitary gland located at the base of the brain. As the tumor grows, it can compress nearby structures such as the optic chiasm, leading to visual disturbances (due to pressure on the optic nerves), severe headache (due to increased intracranial pressure), and altered mental status (due to effects on nearby brain structures).