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: D

Rationale: Tipping Claudia's head back slightly helps in reaching the conjunctival sac easily. The conjunctival sac is a small space between the lower eyelid and the eye itself where eye drops are typically administered. Tilting the head back allows for better access to this area, ensuring the eye drops are delivered accurately and effectively into the eye.

Correct Answer: A

Rationale: In a patient with severe abdominal pain due to end-stage pancreatic cancer, the priority intervention to manage their symptoms would be to provide adequate pain relief. Opioid analgesics are the cornerstone of pain management for cancer patients experiencing severe pain. They work by binding to opioid receptors in the central nervous system, thereby reducing the perception of pain. Opioids are highly effective in managing cancer pain, including abdominal pain, and can significantly improve the patient's quality of life by providing relief from distressing symptoms. Therefore, administering opioid analgesics should be the nurse's primary intervention in this case to address the patient's severe abdominal pain. Initiating enteral nutrition, recommending hot compresses, or referring to a gastroenterologist may be relevant interventions depending on the patient's overall care plan but addressing the pain should be the immediate priority in this scenario.

Correct Answer: C

Rationale: Pituitary adenoma is the most likely neurological condition responsible for the described symptoms of acute onset severe headache, visual disturbances, and altered mental status when a tumor is found compressing the optic chiasm. Pituitary adenomas are benign tumors arising from the pituitary gland located at the base of the brain. As the tumor grows, it can compress nearby structures such as the optic chiasm, leading to visual disturbances (due to pressure on the optic nerves), severe headache (due to increased intracranial pressure), and altered mental status (due to effects on nearby brain structures).

Correct Answer: D

Rationale: The ethical principle of beneficence, which is the basis of every nursing action in all work settings, emphasizes the importance of doing good at all times for the benefit of the patient. Nurses are expected to act in the best interest of their patients and strive to promote their well-being and welfare. This principle guides nurses to provide care that is compassionate, effective, and in line with the patient's needs and preferences. By prioritizing the good of the patient in all actions and decisions, nurses uphold the principle of beneficence and demonstrate their commitment to promoting positive outcomes for those under their care.