Adult Health Nursing Answer Key

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A patient admitted to the ICU develops delirium characterized by acute onset confusion and agitation. What intervention should the healthcare team prioritize to manage the patient's delirium?

  • A. Administer antipsychotic medications to reduce agitation.
  • B. Implement environmental modifications to promote orientation.
  • C. Refer the patient to a psychiatrist for further evaluation.
  • D. Prescribe benzodiazepines for sedation and calming effect.
Correct Answer: B

Rationale: The healthcare team should prioritize implementing environmental modifications to promote orientation in a patient with delirium. Delirium is a state of acute confusion and agitation that can be triggered by various factors such as medications, infections, or metabolic disturbances. Environmental modifications involve creating a calm, quiet, and well-lit environment for the patient. Promoting proper orientation through the use of clocks, calendars, and familiar objects can help reduce confusion and improve the patient's understanding of their surroundings. These interventions are non-pharmacological and aim to address the underlying causes of delirium while minimizing the need for additional medications that may have potential side effects. Antipsychotic medications and benzodiazepines should be used judiciously and under close supervision due to the risk of adverse effects in older adults and critically ill patients. Referring the patient to a psychiatrist may be considered if the delirium is complex or if there are underlying psychiatric issues contributing to the presentation.

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Disclosure of client information beyond the interdisciplinary team without consent of the client is a breach of ______.

  • A. confidentiality
  • B. duty
  • C. beneficence
  • D. veracity
Correct Answer: A

Rationale: Confidentiality is the ethical principle that requires healthcare providers to keep client information private and not disclose it without the client's consent. When client information is shared beyond the interdisciplinary team without the client's consent, it breaches the trust and privacy expected in the nurse-client relationship. This breach not only violates the ethical principle of confidentiality but also undermines the client's autonomy and right to control their own personal information. Maintaining confidentiality is crucial for building trust and ensuring the well-being of the client.

One morning during rounds, Nurse Myra noticed that Marlene was unduly sad. The nurse 's BEST way of communicating her concern is _______.

  • A. whatever it is, you lift it up to God
  • B. saying you are sad again, that is bad for your health
  • C. telling Marlene to stop worrying, everything will be okay
  • D. placing her hand over Marlene 's shoulder and asking why the sad face
Correct Answer: D

Rationale: Placing her hand over Marlene's shoulder and asking why the sad face is the best way for Nurse Myra to communicate her concern. This approach shows empathy and creates a safe space for Marlene to open up about her feelings. By using physical touch and showing genuine interest in Marlene's well-being, Nurse Myra can effectively address the situation and provide appropriate support or guidance as needed. Simply dismissing Marlene's feelings (option B and C) or resorting to religious advice (option A) may not effectively address the underlying cause of Marlene's sadness. It is important in situations like this to show empathy, compassion, and a willingness to listen in order to provide the best support for the individual in distress.

A patient receiving palliative care for end-stage heart failure experiences paroxysmal nocturnal dyspnea. What intervention should the palliative nurse prioritize to manage the patient's symptoms?

  • A. Administer diuretic medications to reduce fluid overload.
  • B. Elevate the head of the bed to improve respiratory mechanics.
  • C. Encourage the patient to sleep in a reclined position to minimize dyspnea.
  • D. Refer the patient to a sleep specialist for evaluation and treatment.
Correct Answer: B

Rationale: Elevating the head of the bed to improve respiratory mechanics is the most appropriate intervention for managing paroxysmal nocturnal dyspnea in a patient with end-stage heart failure. By keeping the head of the bed elevated, gravity helps reduce the pooling of fluid in the lungs, making it easier for the patient to breathe and reducing dyspnea. This strategy can help improve oxygenation and decrease the sensation of breathlessness, providing relief for the patient. Administering diuretic medications (Option A) can also be beneficial to reduce fluid overload, although positioning remains a key intervention. Encouraging the patient to sleep in a reclined position (Option C) can help alleviate symptoms, but specifically elevating the head of the bed is a more targeted approach. Referring the patient to a sleep specialist (Option D) may not be necessary at this time, as the primary concern is managing the acute symptom of paroxysmal nocturnal dyspnea

Which of the following structures is responsible for the mechanical and chemical digestion of food, as well as the absorption of nutrients into the bloodstream?

  • A. Liver
  • B. Stomach
  • C. Pancreas
  • D. Large intestine
Correct Answer: B

Rationale: The stomach is the organ responsible for the mechanical and chemical digestion of food. When food enters the stomach, it is mixed with stomach acid and enzymes to break down the food into smaller particles. This process helps prepare the food for further digestion and absorption of nutrients. The stomach also plays a key role in the absorption of some nutrients, such as certain vitamins and minerals. Additionally, the stomach's muscular contractions help mix the food with digestive enzymes and propel the partially digested food into the small intestine for further processing and absorption. The liver, pancreas, and large intestine have vital functions in the digestive system, but the stomach is the primary organ responsible for the initial digestion and absorption of nutrients.

A nurse ________.

  • A. Has the freedom to do what he likes and responsibilities.
  • B. Is obliged to avoid what is wrong and do what is good.
  • C. Is a person capable of knowing what is right or wrong
  • D. Should have a sense of accountability for his actions
Correct Answer: D

Rationale: A nurse should have a sense of accountability for his actions. This means taking responsibility for one's decisions and behaviors while working in the healthcare setting. Accountability ensures that the nurse is aware of the consequences of his actions and is willing to accept ownership and follow through on commitments. It is a critical aspect of nursing practice as it helps maintain professional standards, promote patient safety, and uphold trust and integrity within the profession. Nurses are entrusted with the well-being of their patients, so being accountable for their actions is essential in providing high-quality care and maintaining ethical standards.

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