Adult Health Nursing Test Bank

Correct Answer: C

Rationale: Step 1: Job description is crucial for clarifying roles and responsibilities, ensuring staff understand their duties. Step 2: Regular review of job descriptions helps align staff performance with organizational goals and expectations. Step 3: It allows for identifying areas of improvement and providing necessary support and resources. Step 4: Academic performance in college, family dynamics, and number of incident reports are not directly related to work performance. Summary: Regularly reviewing staff job descriptions is essential for enhancing performance by clarifying roles, aligning expectations, and identifying areas for improvement. Other choices lack direct relevance to work performance.

Correct Answer: C

Rationale: The correct answer is C: cope with anxiety. The nurse's goal is to address Belle's difficulty tolerating frustration, which likely leads to anxiety. By helping Belle develop coping strategies for managing her anxiety, the nurse can assist her in handling frustration more effectively. Options A, B, and D are incorrect because increasing self-esteem, recognizing needs, and mobilizing resources may be important aspects of Belle's overall care but are not directly related to addressing her difficulty with frustration and anxiety. Focusing on coping with anxiety directly targets the root issue and is the most appropriate goal in this context.

Correct Answer: D

Rationale: The correct answer is D: Trigeminal neuralgia. This condition is characterized by recurrent, severe, stabbing pain in the trigeminal nerve distribution triggered by touch, chewing, or cold exposure. The key feature is the characteristic lancinating pain, which is not typical of migraine (choice A), cluster headache (choice B), or tension-type headache (choice C). Migraine typically presents with pulsating, moderate to severe headache associated with nausea and sensitivity to light and sound. Cluster headache is characterized by severe, unilateral pain around the eye associated with autonomic symptoms. Tension-type headache presents with bilateral, pressing or tightening pain without specific triggers. Therefore, based on the description of the symptoms in the question, trigeminal neuralgia is the most likely diagnosis.

Correct Answer: A

Rationale: The correct answer is A: Central retinal artery occlusion. This condition presents with sudden-onset, painless vision loss, cherry-red spot at the macula due to lack of blood flow, and attenuated retinal vessels. The cherry-red spot is due to the transparency of the fovea when there is ischemia in the surrounding retina. Central retinal vein occlusion (B) presents with sudden vision loss accompanied by retinal hemorrhages and dilated tortuous veins. Retinal detachment (C) typically presents with sudden flashes, floaters, and a curtain-like visual field defect. Acute angle-closure glaucoma (D) presents with severe eye pain, blurred vision, halos around lights, and a fixed mid-dilated pupil.

Correct Answer: A

Rationale: Correct Answer: A - sterile clamps Rationale: 1. **Immediate action**: Sterile clamps are essential to clamp the chest tube to prevent air from entering the pleural space. 2. **Prevent lung collapse**: Clamping the tube will prevent lung collapse and maintain positive pressure in the pleural space. 3. **Buy time**: By clamping the tube, you buy time to properly reattach the tube or secure it with a new connection. 4. **Safety**: Sterile clamps are a quick and effective solution to prevent a potentially life-threatening situation. Summary of other choices: B: Sterile dressing - Not the first priority as the immediate concern is preventing air from entering the pleural space. C: Another chest tube - Not necessary initially as clamping can buy time to reattach the disconnected tube. D: A bottle of sterile water - Not needed for emergency management of a disconnected chest tube.