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: Wearing a mask is an essential infection control measure to prevent the spread of respiratory illnesses, including COVID-19. By wearing a mask, Nurse Emma can reduce the risk of inhaling or exhaling respiratory droplets that may contain infectious particles, thus helping to protect herself and the family members she is visiting. Masks are particularly crucial when interacting with individuals who are sick or when physical distancing may be challenging. While using gloves, face shields, and gowns are also important infection control measures in certain situations, wearing a mask is the most relevant and effective measure during a home visit to prevent respiratory transmission of infections.

Correct Answer: A

Rationale: The behavior of repetitive cleaning in someone diagnosed with obsessive-compulsive disorder is likely an attempt to decrease the anxiety to a tolerable level. People with OCD often engage in compulsive behaviors, such as cleaning, in an effort to alleviate the distress and anxiety caused by obsessive thoughts. This repetitive action provides a sense of control and temporary relief from the anxiety associated with their obsessive thoughts. By engaging in cleaning rituals, individuals with OCD can try to reduce their anxious feelings and create a sense of order and cleanliness in their environment.

Correct Answer: B

Rationale: The nurse's best response when a patient expresses frustration with the healthcare system's inefficiencies is to listen actively to the patient's concerns, acknowledge the challenges they are facing, and offer support. It is important for the nurse to validate the patient's feelings and demonstrate empathy, rather than dismissing or ignoring their frustrations. By offering support and showing understanding, the nurse can help the patient feel heard and valued, which is an essential aspect of providing patient-centered care. This approach can also help to strengthen the nurse-patient relationship and build trust, ultimately leading to better outcomes for the patient's overall healthcare experience.

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.