Adult Health Med Surg Nursing Test Banks

Correct Answer: C

Rationale: Using professional medical interpreters is the best approach when communicating with a patient who speaks a different language. This ensures accurate communication and helps prevent misunderstandings that can have serious consequences for the patient's health. Family members or friends may not be fluent in the necessary medical terminology and could unintentionally misinterpret information. Relying solely on written instructions can also be risky as the patient may have difficulty reading or comprehending the information. Speaking loudly and slowly may come across as disrespectful and does not address the root issue of the language barrier. Professional medical interpreters are trained to facilitate effective communication between healthcare providers and patients, ensuring that the patient receives the best possible care.

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: 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: C

Rationale: NSAIDs are commonly known to increase the risk of gastrointestinal adverse effects, including gastritis, ulcers, and gastrointestinal bleeding. This risk is due to the inhibition of prostaglandin synthesis, which plays a protective role in the gastrointestinal mucosa. Gastrointestinal bleeding can manifest as symptoms such as black, tarry stools, vomiting blood, or abdominal pain. Therefore, it is crucial for the nurse to closely monitor the patient for signs and symptoms of gastrointestinal bleeding while taking NSAIDs to prevent potentially serious complications. Hypotension, hyperkalemia, and hyperglycemia are not commonly associated with NSAIDs use, making them less likely adverse effects to monitor for in this scenario.

Correct Answer: B

Rationale: When a patient receiving palliative care for end-stage COPD expresses a desire to discuss advance care planning, the palliative nurse should initiate a conversation about advance directives and future care preferences. Advance care planning involves discussing and documenting a patient's preferences regarding future medical care, particularly in situations where the patient may no longer be able to make decisions. This discussion helps ensure that the patient's wishes are respected and followed in the event they are unable to communicate their preferences. By engaging in advance care planning discussions, the nurse can help the patient feel empowered, supported, and in control of their medical care decisions. It also allows healthcare providers to align care with the patient's values and goals, ultimately improving quality of life and ensuring dignity at the end of life.