Adult Health Nursing Study Guide Answers

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A patient presents with redness, pain, and photophobia in the left eye. Slit-lamp examination reveals ciliary injection, corneal edema, and a mid-dilated pupil with fixed reaction to light. Which of the following conditions is most likely responsible for this presentation?

  • A. Anterior uveitis
  • B. Acute angle-closure glaucoma
  • C. Endophthalmitis
  • D. Corneal abrasion
Correct Answer: A

Rationale: The presentation described in the question is classic for anterior uveitis. Anterior uveitis is an inflammatory condition affecting the iris and ciliary body and is characterized by redness, pain, and photophobia. Slit-lamp examination typically reveals ciliary injection (redness around the iris), corneal edema, and a mid-dilated pupil with a fixed reaction to light due to inflammation causing spasm of the iris muscles. Acute angle-closure glaucoma would present with similar symptoms but would also have increased intraocular pressure, which is not mentioned in the presentation. Endophthalmitis is an infection of the intraocular cavities and would typically present with more severe symptoms, such as severe pain, vision loss, and presence of pus in the eye. Corneal abrasion would present with pain, foreign body sensation, and possibly tearing but would not cause ciliary injection or fixed pupil reaction as

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During a patient consultation, the nurse notices the patient seems anxious and is avoiding eye contact. What is the most appropriate action for the nurse to take?

  • A. Continue with the consultation without addressing the patient's behavior.
  • B. Ask the patient if they are feeling anxious and if they would like to talk about it.
  • C. Ignore the patient's behavior and focus solely on the medical information.
  • D. Tell the patient to relax and stop being anxious.
Correct Answer: B

Rationale: The most appropriate action for the nurse to take when noticing that the patient seems anxious and is avoiding eye contact is to ask the patient if they are feeling anxious and if they would like to talk about it. This approach shows empathy, concern, and openness to addressing the patient's emotional state. By directly acknowledging the patient's behavior and giving them the opportunity to express their feelings, the nurse can create a supportive and caring environment that promotes effective communication and trust between the patient and healthcare provider. It is important to consider the patient's emotional well-being alongside their physical health during consultations.

While the nurse is taking yhe blood pressure, the patient suddenly stated."They are talking about me!". She was referring to other patients who were waiting for their consultation. Which of the following should be the APPROPRIATE nursing action?

  • A. Present the reality situation
  • B. Distract patient's attention
  • C. Disagree with the patient
  • D. Validate the statement
Correct Answer: B

Rationale: The appropriate nursing action in this situation would be to distract the patient's attention. When a patient perceives that others are talking about them, it may indicate feelings of paranoia or anxiety. It's important to help the patient refocus on something else to alleviate their distress. Distracting the patient's attention can help calm them down and allow the blood pressure measurement to proceed smoothly. This approach respects the patient's feelings and helps manage the situation effectively.

Nurse Bea reviewed the elements of nursing as a profession. Which of the following is an IMPORTANT element that characterizes Nursing as a profession ?

  • A. Has members
  • B. Possess body of knowledge
  • C. Service oriented
  • D. A calling
Correct Answer: B

Rationale: Possessing a body of knowledge is an important element that characterizes nursing as a profession. Nursing is a field that requires specialized education, training, and expertise in various areas of healthcare. Nurses are expected to have a comprehensive understanding of anatomy, physiology, pharmacology, and various nursing theories and practices to effectively care for patients. This body of knowledge distinguishes nursing as a profession and supports the delivery of high-quality, evidence-based patient care. While the other options (having members, being service-oriented, and a calling) are also important aspects of nursing, possessing a body of knowledge is fundamental to the profession's identity and practice.

In caring for this patient suffering from anorexia nervous, which task can be delegated to the nursing assistant?

  • A. Obtaining special food for the patient when she request it
  • B. Sitting with the patient during meals and for about an hour after/meals
  • C. Weighing the patient daily and reinforcing that she is underweight
  • D. Observing for reporting ritualistic behaviors related to food
Correct Answer: A

Rationale: Task A, obtaining special food for the patient when she requests it, can be delegated to the nursing assistant. This task involves simple assistance with gathering food items and does not require specific medical knowledge or interventions. Tasks B, C, and D involve more direct patient care and assessment, which should be performed by the nursing staff who have the necessary training and expertise to address the complexities of anorexia nervosa.

A patient admitted to the ICU develops septic shock with refractory hypotension despite fluid resuscitation. Which intervention should the healthcare team prioritize to improve the patient's hemodynamic status?

  • A. Administer vasopressor medications to increase systemic vascular resistance.
  • B. Initiate continuous renal replacement therapy (CRRT) for fluid removal.
  • C. Perform a bedside echocardiogram to assess cardiac function.
  • D. Recommend a transfusion of packed red blood cells to optimize oxygen delivery.
Correct Answer: A

Rationale: In a patient with septic shock and refractory hypotension despite fluid resuscitation, the healthcare team should prioritize administering vasopressor medications to increase systemic vascular resistance. Vasopressors such as norepinephrine or vasopressin can be used to support blood pressure and perfusion to vital organs by constricting blood vessels and improving blood flow. By increasing systemic vascular resistance, vasopressors help to counteract the excessive vasodilation seen in septic shock and improve hemodynamic stability. It is crucial to address hypotension promptly in septic shock to prevent organ dysfunction and failure. Other interventions, such as fluid removal through continuous renal replacement therapy, assessing cardiac function with echocardiogram, or optimizing oxygen delivery through a transfusion of packed red blood cells, may be considered based on specific patient factors but do not address the primary issue of inadequate perf

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