Review Adult Health med surg (Viterbo university)

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Adult Health med surg (Viterbo university)

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Total Questions : 80

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Question 1:

A patient has a traumatic brain injury. The nurse assesses the following: Pulse change from 82 to 60 beats/min, Pulse pressure increase from 26 to 40 mm Hg, and Respiratory irregularities. What action by the nurse takes priority?

A. Increase the rate of the IV fluid administration. B. Notify the provider immediately. C. Prepare to give IV pain medication. D. Notify respiratory therapy for a breathing treatment.

Answer and Explanation

Choice A:

Increasing the rate of IV fluid administration is not the priority action in this situation. Although maintaining adequate fluid levels is important for patients with traumatic brain injuries, the symptoms described (pulse change, increased pulse pressure, and respiratory irregularities) indicate that the patient may be experiencing increased intracranial pressure (ICP). Fluid administration alone will not address this issue and could potentially worsen the condition if not managed carefully.

Choice B:

The priority action is to notify the provider immediately. The changes in vital signs (decreased pulse, increased pulse pressure, and respiratory irregularities) suggest that the patient may be experiencing increased intracranial pressure (ICP), which is a medical emergency. Immediate notification of the provider is essential for timely intervention to prevent further neurological damage or complications.

Choice C:

Preparing to give IV pain medication is not the priority in this situation. While managing pain is important, the patient's vital sign changes indicate a more serious underlying issue (potential increased intracranial pressure) that requires immediate medical attention. Pain medication alone will not address the root cause of the symptoms.

Choice D:

Notifying respiratory therapy for a breathing treatment is not the priority action in this scenario. Although respiratory irregularities are present, the vital sign changes suggest that the patient is experiencing increased intracranial pressure. This requires immediate medical intervention by the provider to manage the underlying condition, rather than solely focusing on respiratory support.

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Question 2:

A patient with a spinal cord lesion at T4 tells the nurse that he has a headache and feels flushed. The blood pressure is significantly elevated to 190/100. The first action by the nurse is to:

A. Recheck all of the patient's vital signs. B. Elevate the patient's knees and lower the head of the bed. C. Elevate the head of the bed immediately and notify the provider. D. Administer PRN Tylenol for the patient's headache.

Answer and Explanation

Choice A:

Rechecking all of the patient's vital signs is a good practice, but it is not the priority action in this scenario. The patient's symptoms indicate a potential case of autonomic dysreflexia, a life-threatening condition that requires immediate action to reduce blood pressure and address the cause. Rechecking vital signs alone will not resolve the underlying issue.

Choice B:

Elevating the patient's knees and lowering the head of the bed is not an appropriate action in this situation. This position could potentially increase intracranial pressure and exacerbate the patient's condition. The focus should be on measures that will help lower the blood pressure and alleviate the symptoms of autonomic dysreflexia.

Choice C:

The priority action is to elevate the head of the bed immediately and notify the provider. Elevating the head of the bed helps to decrease blood pressure and improve venous return. Promptly notifying the provider ensures that the patient receives timely medical intervention to address the underlying cause of autonomic dysreflexia, which is critical for preventing further complications.

Choice D:

Administering PRN Tylenol for the patient's headache is not the priority in this situation. While pain management is important, the patient's symptoms suggest a more severe condition (autonomic dysreflexia) that requires immediate attention to lower blood pressure and address the root cause. Pain medication alone will not resolve the underlying issue and could delay necessary interventions.

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Question 3:

When providing care for a client hospitalized with acute pancreatitis who has acute abdominal pain, which nursing interventions would be most appropriate for this client? Select all that apply.

A. Place the client in a side-lying position. B. Administer hydromorphone for pain as prescribed. C. Obtain daily weights. D. Maintain a high-calorie, high-protein diet. E. Monitor the client's respiratory status.

Answer and Explanation

Choice A:

Placing the client in a side-lying position is beneficial for comfort and can help alleviate pain in clients with acute pancreatitis. This position can reduce pressure on the pancreas and improve circulation, helping to manage pain and discomfort effectively.

Choice B:

Administering hydromorphone for pain as prescribed is essential in managing acute abdominal pain associated with acute pancreatitis. Pain control is a priority in the care of these clients because unmanaged pain can lead to increased stress and further complications. Hydromorphone, a potent opioid analgesic, helps to effectively manage severe pain.

Choice C:

Obtaining daily weights is important for monitoring a client's nutritional status and fluid balance, but it is not directly related to the immediate management of acute abdominal pain in acute pancreatitis. While it is a relevant intervention, it is not as critical as the other measures listed.

Choice D:

Maintaining a high-calorie, high-protein diet is not appropriate for a client with acute pancreatitis. In fact, clients with acute pancreatitis are often placed on a nil-per-os (NPO) status initially to rest the pancreas and reduce enzyme secretion. Once the inflammation subsides, a low-fat, bland diet may be introduced gradually.

Choice E:

Monitoring the client's respiratory status is crucial because clients with acute pancreatitis are at risk for respiratory complications, such as pleural effusion, acute respiratory distress syndrome (ARDS), or atelectasis. Close monitoring ensures early detection and intervention for any respiratory issues that may arise.

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Question 4:

A nursing student learns about modifiable risk factors for coronary artery disease. Which factors does this include? Select all that apply.

A. Age B. Hypertension C. Obesity D. Smoking E. Stress

Answer and Explanation

Choice A:

Age is a non-modifiable risk factor for coronary artery disease. While it is a significant risk factor, individuals cannot change their age. Modifiable risk factors are those that individuals can alter through lifestyle changes or medical interventions to reduce their risk of developing coronary artery disease.

Choice B:

Hypertension, or high blood pressure, is a modifiable risk factor for coronary artery disease. By managing blood pressure through lifestyle changes, medications, and regular monitoring, individuals can reduce their risk of developing coronary artery disease. Effective management of hypertension includes reducing sodium intake, maintaining a healthy weight, exercising regularly, and taking prescribed medications.

Choice C:

Obesity is a modifiable risk factor for coronary artery disease. Individuals can work towards achieving and maintaining a healthy weight through dietary changes, increased physical activity, and behavioral modifications. Losing weight can significantly lower the risk of coronary artery disease by improving blood pressure, cholesterol levels, and overall cardiovascular health.

Choice D:

Smoking is a major modifiable risk factor for coronary artery disease. Quitting smoking can dramatically reduce the risk of developing coronary artery disease and other cardiovascular conditions. Smoking cessation programs, medications, and support groups can help individuals successfully quit smoking and improve their cardiovascular health.

Choice E:

Stress is a modifiable risk factor for coronary artery disease. Chronic stress can contribute to the development of coronary artery disease by affecting blood pressure, cholesterol levels, and overall heart health. Managing stress through relaxation techniques, exercise, counseling, and mindfulness practices can help reduce the risk of coronary artery disease.

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Question 5:

Which client warrants immediate intervention by the nurse?
a) The client with a heart rate of 56/min and a blood pressure of 110/70.
b) The client diagnosed with mitral valve regurgitation who has a thready peripheral pulse.
c) The client diagnosed with pericarditis who has chest pain with inspiration.
d) The client with a history of atrial fibrillation who has developed slurred speech.

The correct answer is: d) The client with a history of atrial fibrillation who has developed slurred speech.

Choice A reason: A heart rate of 56/min and a blood pressure of 110/70, while slightly lower than normal, may not require immediate intervention unless accompanied by other symptoms. Bradycardia (a slow heart rate) and this blood pressure reading can be within acceptable limits for some individuals, especially if they are asymptomatic.
Choice B reason: Mitral valve regurgitation with a thready peripheral pulse indicates a decrease in cardiac output, which can be concerning. However, it may not require immediate intervention unless the client shows signs of severe decompensation or other critical symptoms. Continuous monitoring and evaluation are essential, but immediate action might not be necessary.
Choice C reason: Chest pain with inspiration in a client with pericarditis can be a symptom of the condition itself, which involves inflammation of the pericardium. While pain management and monitoring are important, this symptom alone may not necessitate immediate intervention unless it is severe or accompanied by other alarming signs.
Choice D reason: The development of slurred speech in a client with a history of atrial fibrillation is a critical symptom that warrants immediate intervention. Slurred speech can be a sign of a stroke or transient ischemic attack (TI

A. The client with a heart rate of 56/min and a blood pressure of 110/70. B. The client diagnosed with mitral valve regurgitation who has a thready peripheral pulse. C. The client diagnosed with pericarditis who has chest pain with inspiration. D. The client with a history of atrial fibrillation who has developed slurred speech.

Answer and Explanation

Choice A:

A heart rate of 56/min and a blood pressure of 110/70, while slightly lower than normal, may not require immediate intervention unless accompanied by other symptoms. Bradycardia (a slow heart rate) and this blood pressure reading can be within acceptable limits for some individuals, especially if they are asymptomatic.

Choice B:

Mitral valve regurgitation with a thready peripheral pulse indicates a decrease in cardiac output, which can be concerning. However, it may not require immediate intervention unless the client shows signs of severe decompensation or other critical symptoms. Continuous monitoring and evaluation are essential, but immediate action might not be necessary.

Choice C:

Chest pain with inspiration in a client with pericarditis can be a symptom of the condition itself, which involves inflammation of the pericardium. While pain management and monitoring are important, this symptom alone may not necessitate immediate intervention unless it is severe or accompanied by other alarming signs.

Choice D:

The development of slurred speech in a client with a history of atrial fibrillation is a critical symptom that warrants immediate intervention. Slurred speech can be a sign of a stroke or transient ischemic attack (TIA), both of which require urgent medical attention. Immediate action is needed to evaluate and manage the client's condition to prevent further complications.

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Question 6:

A nurse cares for a patient who has cirrhosis of the liver. What action would the nurse take to decrease the presence of ascites?

A. Monitor intake and output. B. Provide a low-sodium diet. C. Increase oral fluid intake. D. Weigh the patient daily.

Answer and Explanation

Choice A:

Monitoring intake and output is important in managing cirrhosis and ascites, as it helps track fluid balance and detect early signs of fluid retention. However, this action alone does not directly decrease the presence of ascites. It is more of a monitoring tool than an intervention that reduces fluid accumulation.

Choice B:

Providing a low-sodium diet is a key intervention to decrease the presence of ascites in patients with cirrhosis. Sodium restriction helps prevent fluid retention by reducing the amount of sodium in the bloodstream, which in turn decreases the osmotic pressure that draws fluid into the abdominal cavity. This dietary modification is fundamental in the management of ascites.

Choice C:

Increasing oral fluid intake is not an appropriate action for decreasing the presence of ascites in patients with cirrhosis. Excessive fluid intake can exacerbate fluid retention and worsen ascites. Instead, fluid intake may need to be restricted depending on the patient's condition and electrolyte balance.

Choice D:

Weighing the patient daily is a useful tool for monitoring fluid status and detecting changes in ascites. However, similar to monitoring intake and output, this action does not directly decrease the presence of ascites. It serves as a means to track the effectiveness of other interventions, such as sodium restriction and medication.

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Question 7:

A nurse recognizes that alterations in cardiac output are caused by changes in heart rate, preload, afterload, and contractility. Which interventions are correctly matched to treat the cause of low cardiac output? Select all that apply.
a) Low afterload: administer vasopressor.
b) Low afterload: administer vasodilator.
c) Low right atrial (R

A. Low afterload: administer vasopressor. B. Low afterload: administer vasodilator. C. Low right atrial (RA) pressure: administer diuretics. D. Low preload: administer fluid bolus. E. High preload: administer diuretic or vasodilator.

Answer and Explanation

Choice A:

Administering a vasopressor is not appropriate for low afterload. Vasopressors are used to increase blood pressure by causing vasoconstriction, which increases afterload. However, the administration of a vasopressor for low afterload is contradictory because the goal for low afterload would be to reduce the strain on the heart, not to increase it.

Choice B:

Administering a vasodilator for low afterload is not correct. Vasodilators decrease afterload by causing the blood vessels to widen, reducing the resistance the heart has to pump against. Administering a vasodilator to treat low afterload is inappropriate because it would further lower afterload, potentially leading to inadequate perfusion and worsening cardiac output.

Choice C:

Administering diuretics for low right atrial (RA) pressure is inappropriate. Diuretics help to remove excess fluid from the body, reducing blood volume and venous pressure. However, if a patient has low right atrial pressure, reducing blood volume further with diuretics could exacerbate the issue, leading to decreased cardiac output and poor perfusion.

Choice D:

Administering a fluid bolus is the correct intervention for low preload. Preload refers to the volume of blood in the ventricles at the end of diastole. If preload is low, administering fluids increases blood volume, which enhances ventricular filling and improves cardiac output. This intervention helps to stabilize hemodynamics and improve overall perfusion.

Choice E:

Administering a diuretic or vasodilator is the appropriate intervention for high preload. High preload indicates an excess of blood volume returning to the heart, which can strain the cardiac muscle and reduce efficiency. Diuretics help remove excess fluid, while vasodilators decrease venous return and reduce the volume of blood the heart has to handle, thus optimizing cardiac function and output.

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Question 8:

Which treatment best applies to the care of a client newly diagnosed with infective endocarditis?

A. Complete bedrest for the duration of the treatment with subcutaneous enoxaparin. B. Long-term anticoagulant therapy with IV heparin followed by oral warfarin. C. Administration of IV penicillin, followed by oral penicillin for 10 weeks. D. Hospitalization for initial IV antibiotics, followed by continued IV antibiotics at home.

Answer and Explanation

Choice A:

Complete bedrest for the duration of the treatment with subcutaneous enoxaparin is not the best approach for managing infective endocarditis. While bed rest may be recommended initially to reduce cardiac workload, long-term bed rest is not necessary and could lead to complications such as muscle atrophy or thromboembolism. Subcutaneous enoxaparin is used for prophylaxis against deep vein thrombosis, but it does not address the underlying infection.

Choice B:

Long-term anticoagulant therapy with IV heparin followed by oral warfarin is not the standard treatment for infective endocarditis. Although anticoagulant therapy may be necessary in some cases, such as for patients with prosthetic valves or specific cardiac conditions, it is not the primary treatment for the infection itself. The focus should be on eradicating the infection with appropriate antibiotics.

Choice C:

Administration of IV penicillin, followed by oral penicillin for 10 weeks, is not the typical treatment regimen for infective endocarditis. While penicillin may be part of the antibiotic therapy, the duration and route of administration need to be tailored to the specific causative organism and the patient's clinical condition. Usually, a combination of antibiotics and a specific treatment plan is developed based on culture and sensitivity results.

Choice D:

Hospitalization for initial IV antibiotics, followed by continued IV antibiotics at home, is the best treatment approach for a client newly diagnosed with infective endocarditis. This allows for intensive management and monitoring during the critical initial phase of treatment, ensuring that the infection is adequately controlled. Transitioning to continued IV antibiotics at home provides the necessary long-term therapy while allowing the patient to recover in a familiar environment. This approach ensures compliance with the treatment regimen and reduces the risk of complications.

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Question 9:

A nurse is caring for a patient who experienced a cervical spine injury 12 hours ago and is experiencing spinal shock. Which of the following medications should the nurse anticipate giving?

A. Albumin B. Nitroprusside C. Dexamethasone D. Furosemide

Answer and Explanation

Choice A:

Albumin is a plasma expander and is typically used to restore blood volume in cases of shock, burns, or trauma. However, it is not specifically indicated for managing spinal shock. Albumin helps in maintaining osmotic pressure and fluid balance but does not directly address the underlying pathophysiology of spinal shock.

Choice B:

Nitroprusside is a potent vasodilator used to manage hypertensive crises. It works by rapidly reducing blood pressure through vasodilation. In the context of spinal shock, where hypotension is a concern, administering nitroprusside would be inappropriate as it could exacerbate the hypotensive state and worsen the patient's condition.

Choice C:

Dexamethasone, a corticosteroid, is used to reduce inflammation and edema around the spinal cord following an injury. The anti-inflammatory properties of dexamethasone help to mitigate secondary damage caused by swelling and pressure on the spinal cord tissue. It is commonly administered in cases of acute spinal cord injuries to improve neurological outcomes and manage symptoms of spinal shock.

Choice D:

Furosemide is a diuretic used to manage fluid overload and edema. It works by increasing urine output, which can help reduce fluid retention in various conditions, such as heart failure and renal impairment. However, it is not specifically indicated for the management of spinal shock and does not address the underlying causes of spinal cord injury-related inflammation and edema.

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Question 10:

A nurse assesses a patient in an outpatient clinic. Which statement alerts the nurse to the possibility of left-sided heart failure?

A. I must stop halfway up the stairs to catch my breath. B. I am awakened by the need to urinate at night. C. I have been drinking more water than usual. D. I have experienced blurred vision on several occasions.

Answer and Explanation

Choice A:

The statement "I must stop halfway up the stairs to catch my breath" is a significant indicator of left-sided heart failure. Left-sided heart failure leads to pulmonary congestion, resulting in symptoms such as shortness of breath, especially during physical activities. This occurs because the heart is unable to effectively pump blood to the body, causing fluid buildup in the lungs and leading to exertional dyspnea.

Choice B:

The statement "I am awakened by the need to urinate at night" refers to nocturia, which can be associated with heart failure but is not as specific to left-sided heart failure as exertional dyspnea. Nocturia can occur due to fluid redistribution when lying down, but it is not a definitive sign of left-sided heart failure alone.

Choice C:

The statement "I have been drinking more water than usual" is not directly related to left-sided heart failure. Increased water intake could be indicative of other conditions such as diabetes or dehydration, but it is not a specific symptom of left-sided heart failure.

Choice D:

The statement "I have experienced blurred vision on several occasions" is not typically associated with left-sided heart failure. Blurred vision can result from various causes, including visual disturbances, blood pressure changes, or other medical conditions, but it is not a hallmark symptom of left-sided heart failure.

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