Adult Health Nursing Test Banks

Correct Answer: A

Rationale: In this critical situation, the safety of the wife is of utmost importance. Whenever a healthcare provider becomes aware of a direct threat to someone's safety, especially related to potential harm or violence, it is their ethical and legal responsibility to report this information to the appropriate authorities promptly. In this case, the nurse should alert the proper authorities, such as law enforcement or a mental health crisis team, to ensure that immediate steps are taken to protect the wife from harm. Confidentiality should be breached in situations where there is a clear threat to an individual's safety. Keeping the information confidential in this scenario could result in serious harm or even loss of life. The nurse must act quickly to protect the potential victim.

Correct Answer: C

Rationale: Placing a patient in restraints before utilizing other less restrictive interventions violates the patient's right to receive treatment in the least restrictive environment. Restraints should be used as a last resort when all other options have been exhausted, as they can be restrictive to the patient's movement and freedom. Patients have the right to be treated in a manner that minimizes limitations on their personal freedom and autonomy. Restraints should only be utilized when absolutely necessary for the safety of the patient or others.

Correct Answer: A

Rationale: The BEST position for a patient in shock is the modified Trendelenburg position. In this position, the patient's legs are elevated above the level of the heart to enhance blood flow back to the heart and vital organs. Placing the patient in the modified Trendelenburg position helps increase venous return, improves cardiac output, and promotes perfusion to vital organs, which can be crucial in managing shock. This position can help stabilize the patient's condition while awaiting further medical intervention.

Correct Answer: A

Rationale: Grilled chicken breast is a suitable choice for a low-phosphorus diet because poultry is typically lower in phosphorus compared to dairy products (like cheese), nuts (like almonds), and whole grains (like wheat toast). This option indicates an understanding of the need to restrict phosphorus intake, which is important for individuals with chronic kidney disease to prevent complications.

Correct Answer: D

Rationale: Administering oxygen inhalation is the priority nursing action for a patient presenting with clinical manifestations related to endocrine disorders. Patients with hyperthyroidism, Cushing syndrome, and hypothyroidism can all experience respiratory distress due to various reasons such as thyroid storm, adrenal crisis, or myxedema coma. Oxygen inhalation helps improve oxygenation and tissue perfusion, providing immediate support to the patient's respiratory system. It is crucial to ensure adequate oxygenation before addressing other assessments or interventions. Once the patient's breathing is stabilized, further assessments and treatments can be initiated as necessary.