Adult Health Med Surg Nursing Test Banks

Correct Answer: D

Rationale: The assessment finding that is indicative of the diagnosis of hypertension is consistent evaluation of blood pressure. Hypertension is diagnosed based on repeated measurements of elevated blood pressure. Consistently high blood pressure readings, usually defined as systolic blood pressure consistently at or above 140 mmHg and diastolic blood pressure consistently at or above 90 mmHg, are a key factor in diagnosing hypertension. Family history of high blood pressure (Choice A), elevation of blood cholesterol level (Choice B), and a stressful work environment (Choice C) may be risk factors for hypertension but are not diagnostic criteria. In order to diagnose hypertension, healthcare providers rely on consistent measurement and evaluation of blood pressure over time.

Correct Answer: A

Rationale: The PRIORITY nursing action when receiving information about suspected child abuse is to report to the police authorities. Child abuse is a serious issue that requires immediate intervention to ensure the safety and well-being of the child. The police are trained to investigate these types of situations and can take the necessary steps to protect the child from harm. It is essential to act swiftly and report any suspicions of child abuse to the proper authorities to prevent further harm and ensure the child's safety.

Correct Answer: C

Rationale: Preoperative nursing intervention that is essential for preparing a patient with a history of coronary artery disease for coronary artery bypass graft (CABG) surgery is assisting the patient with deep breathing and coughing exercises. These exercises are crucial to prevent postoperative complications such as atelectasis and pneumonia, which are common risks after surgery. Deep breathing exercises help to expand the lungs and improve ventilation, while coughing exercises help to clear secretions and prevent respiratory complications. By assisting the patient with these exercises preoperatively, the nurse can help optimize the patient's respiratory function and decrease the risk of complications during and after surgery. Administering aspirin, providing education about pain management, and obtaining informed consent are also important aspects of preoperative care, but assisting with deep breathing and coughing exercises is particularly essential for patients undergoing CABG surgery due to the increased risk of respiratory complications in this population.

Correct Answer: A

Rationale: The patient's presentation of recurrent episodes of sudden, severe vertigo lasting hours with nausea, vomiting, and nystagmus, along with unilateral weakness on vestibular function tests, is most consistent with vestibular neuritis. Vestibular neuritis is characterized by inflammation of the vestibular nerve leading to sudden onset vertigo that can last for hours to days. It is often associated with nausea, vomiting, and nystagmus. Unilateral weakness on vestibular function tests indicates dysfunction of one vestibular system. Differential diagnosis for this type of presentation includes other conditions such as Meniere's disease, BPPV, and acoustic neuroma. However, the combination of symptoms and unilateral vestibular weakness makes vestibular neuritis the most likely diagnosis in this case.

Correct Answer: B

Rationale: The nurse should prioritize cleansing the insertion site with an alcohol-based antiseptic solution to maintain procedural asepsis during a peripherally inserted central catheter (PICC) insertion. Proper skin preparation is essential in reducing the risk of introducing pathogens into the patient's bloodstream during the insertion process. Alcohol-based antiseptic solutions are effective in reducing the number of microorganisms on the skin surface. Wearing sterile gloves and following other sterile techniques are also crucial, but preparing the insertion site with the antiseptic solution is the initial step in maintaining asepsis during the procedure.