Adult Health Nursing Test Banks

Correct Answer: A

Rationale: Battery refers to the intentional touching of another person without consent, resulting in harm or offense. In this scenario, the nurse inserted the urinary catheter into the client's urethra without the client's consent, leading to an injury. This action constitutes battery as the nurse carried out a medical procedure without the client's permission, resulting in harm to the client. The client can sue the nurse for battery in this situation.

Correct Answer: D

Rationale: In end-stage liver disease, pruritus (itching) can be a distressing symptom caused by the accumulation of bile salts in the skin due to impaired liver function. Cholestyramine and other bile acid sequestrants are the primary treatment for managing pruritus in these patients. These medications bind to the bile salts in the intestine, preventing their reabsorption and reducing the itching symptoms. Antihistamines may not be as effective for this type of pruritus since it is not histamine-mediated. Topical corticosteroids are generally not recommended for long-term use in liver disease due to the risk of systemic absorption and adverse effects. Avoiding hot showers or baths may provide some temporary relief but is not a definitive treatment. Therefore, prioritizing the prescription of cholestyramine or bile acid sequestrants would be the most appropriate intervention to address the severe pruritus in a patient with end-stage liver disease

Correct Answer: C

Rationale: Choosing option C, asking the patient about their cultural beliefs and preferences related to pain, demonstrates cultural competence in pain assessment. Pain experiences can vary greatly across different cultures, and a patient's cultural background can influence how they perceive and express pain. By inquiring about the patient's cultural beliefs and preferences, the nurse can gain a better understanding of the patient's perspective on pain. This information is crucial for providing individualized and culturally sensitive pain management interventions. It also shows respect for the patient's unique cultural background and helps build a trusting and collaborative relationship between the nurse and the patient.

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.

Correct Answer: D

Rationale: The diagnosis of gestational diabetes mellitus (GDM) is typically confirmed through an oral glucose tolerance test (OGTT) during pregnancy. In GDM, the 2-hour plasma glucose level during the OGTT is equal to or greater than 140 mg/dL. This finding is characteristic of GDM and distinguishes it from other types of diabetes. Fasting blood glucose ?126 mg/dL is diagnostic of diabetes mellitus outside of pregnancy, not specifically GDM. Random plasma glucose ?200 mg/dL is indicative of uncontrolled diabetes in general. Hemoglobin A1c (HbA1c) ?6.5% is used for diagnosing diabetes outside of pregnancy and is not specific to GDM.