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: C

Rationale: Before initiating hydrotherapy for pain relief during labor, the nurse's priority action should be to assess the maternal and fetal conditions to determine if the mother is eligible for this form of pain management. It is essential to ensure that hydrotherapy is safe and appropriate for the specific situation. Assessing the maternal condition includes evaluating factors such as the stage of labor, maternal and fetal well-being, and any medical conditions that could impact the use of hydrotherapy. This assessment helps to identify any contraindications or risks that may affect the mother and baby during hydrotherapy. By conducting a thorough assessment, the nurse can make an informed decision about whether hydrotherapy is suitable for the woman in labor.

Correct Answer: B

Rationale: The patient's presentation of severe headache, blurred vision, and fatigue, along with the laboratory findings of elevated white blood cell count, thrombocytosis, and JAK2 V617F mutation, are characteristic of essential thrombocythemia. This is a myeloproliferative neoplasm characterized by the clonal proliferation of megakaryocytes, leading to an increased platelet count. The JAK2 V617F mutation is commonly found in essential thrombocythemia and other myeloproliferative disorders. The symptoms of essential thrombocythemia can be related to the increased blood viscosity and risk of thrombosis due to the elevated platelet count. Polycythemia vera would present with elevated red blood cell count, hemoglobin, and hematocrit, along with other features such as pruritus after a hot bath. Chronic myeloid leukemia (CML

Correct Answer: A

Rationale: The correct statement that indicates the teaching goal has been met is when the client says, "The spray should be used round-the-clock at equally spaced intervals." This statement shows an understanding of how to properly use the decongestant nasal spray as instructed by the nurse. Using the spray round-the-clock at equally spaced intervals helps maintain consistent relief from congestion without the risk of overuse or rebound effects. This response indicates that the client has grasped the correct usage instructions for the decongestant nasal spray, which is the goal of the teaching.

Correct Answer: C

Rationale: The most appropriate nursing action when a postpartum client presents with persistent, severe headache, photophobia, and altered mental status is to notify the healthcare provider immediately. These symptoms could be indicative of serious conditions such as postpartum preeclampsia or postpartum eclampsia, both of which require prompt medical evaluation and intervention. Delaying medical attention in such cases can lead to severe complications for the mother. Therefore, it is crucial to prioritize the client's safety and well-being by quickly involving the healthcare provider for further assessment and management.