Adult Health Nursing Answer Key

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A patient presents with sudden-onset weakness and sensory loss on one side of the body along with difficulty speaking and understanding speech. Imaging reveals an acute infarction involving the right middle cerebral artery territory. Which of the following neurological conditions is most likely responsible for these symptoms?

  • A. Transient ischemic attack (TIA)
  • B. Intracerebral hemorrhage
  • C. Ischemic stroke
  • D. Subarachnoid hemorrhage
Correct Answer: C

Rationale: The patient is presenting with sudden-onset weakness and sensory loss on one side of the body along with difficulty speaking and understanding speech, which are classic symptoms of a stroke. The involvement of the right middle cerebral artery territory on imaging suggests an acute infarction, confirming an ischemic stroke. Ischemic stroke occurs due to a blockage or obstruction within a blood vessel supplying blood to the brain, leading to a lack of oxygen and nutrients reaching brain tissue. This results in neurological deficits corresponding to the affected area of the brain. In contrast, a transient ischemic attack (TIA) would present with similar symptoms but resolve within 24 hours without evidence of acute infarction on imaging. Intracerebral hemorrhage and subarachnoid hemorrhage involve bleeding into the brain tissue or the space surrounding the brain, respectively, resulting in different clinical presentations.

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which is the 'MAIN' goal of ethical practice of the nursing profession including the community setting?

  • A. To protect the nurse and co workers
  • B. To prevent reprimand from physician
  • C. For the patients Family satisfaction
  • D. Centered on the welfare of clients and protect their rights
Correct Answer: D

Rationale: The main goal of ethical practice in the nursing profession, including in the community setting, is centered on the welfare of clients and protecting their rights. Nurses have a professional and ethical obligation to prioritize the well-being and best interests of their patients. This includes providing high-quality care, advocating for their patients, supporting their autonomy, and upholding their rights. Ethical nursing practice is not focused on protecting the nurse or co-workers, preventing reprimand from physicians, or solely meeting the satisfaction of patients' families. Ensuring the welfare and rights of clients is the fundamental ethical principle that guides nursing practice.

As Nurse Pedrito prepares for the day's visits, which of the following patients should be seen FIRST? A client with ________.

  • A. Parkinson's disease with imbalance gait.
  • B. A thoracostomy six months ago.
  • C. A history of congestive heart failure with dyspnea.
  • D. A stroke with nasogastric tube (NGT).
Correct Answer: C

Rationale: The patient with a history of congestive heart failure and dyspnea should be seen FIRST by Nurse Pedrito. Congestive heart failure is a serious condition that can lead to acute exacerbations and requires prompt assessment and management. Dyspnea (shortness of breath) is a common symptom of heart failure and can indicate worsening cardiac function or fluid overload, which requires immediate attention to prevent further complications. Timely assessment and intervention for heart failure exacerbations can help prevent hospital admissions and improve patient outcomes. Therefore, prioritizing this patient for assessment and intervention is crucial to ensure their safety and well-being.

A nurse is preparing to assist with a transurethral resection of the prostate (TURP) procedure for a patient with benign prostatic hyperplasia (BPH). What action should the nurse prioritize to prevent fluid overload during TURP?

  • A. Monitoring the patient's serum electrolyte levels during the procedure
  • B. Administering diuretic medications to the patient before the procedure
  • C. Limiting the duration of irrigation fluid instillation during TURP
  • D. Adjusting the irrigation fluid temperature to promote hemostasis
Correct Answer: C

Rationale: During a transurethral resection of the prostate (TURP), fluid irrigation is commonly used to distend the bladder and flush out tissue debris. However, it is important to prioritize preventing fluid overload in the patient. Limiting the duration of irrigation fluid instillation is a crucial action to prevent excessive fluid absorption and subsequent fluid overload. Prolonged irrigation may lead to an increased risk of fluid overload and electrolyte imbalances, which can result in serious complications such as hyponatremia and fluid volume excess. Monitoring the patient's serum electrolyte levels can be important, but limiting the duration of irrigation is a more immediate and proactive measure to prevent fluid overload. Administering diuretic medications before the procedure may not be appropriate without assessing the patient's specific fluid status and needs. Adjusting the irrigation fluid temperature, while important for hemostasis, does not directly

When the patient was informed about induction, she asks Nurse Aurora what it is all about. which of the following statement by the nurse is correct? Induction is a

  • A. local anesthesia used for blocking pain during episiotomy
  • B. deliberate initiation of uterine contractions that stimulates labor
  • C. medication injected into the subarachnoid space and has a rapid onset of action
  • D. procedure per formed by artificial rupture of the membranes
Correct Answer: B

Rationale: Induction is the deliberate initiation of uterine contractions that stimulates labor. It is usually initiated when natural labor is not progressing or is overdue. This process can involve the use of medications or other methods to help the uterus contract and initiate labor. Option B accurately describes induction, making it the correct answer in this case.

A patient presents with a painful thyroid nodule and signs of hypothyroidism. Fine-needle aspiration biopsy reveals Hurthle cells with nuclear features suggestive of malignancy. Which endocrine disorder is most likely responsible for these symptoms?

  • A. Hashimoto's thyroiditis
  • B. Graves' disease
  • C. Diabetes mellitus
  • D. Hurthle cell carcinoma
Correct Answer: D

Rationale: Hurthle cell carcinoma is a subtype of thyroid cancer that arises from the follicular cells in the thyroid gland. Patients with Hurthle cell carcinoma may present with a painful thyroid nodule, which can be associated with signs of hypothyroidism due to the disruption of thyroid hormone production by the tumor. Fine-needle aspiration biopsy revealing Hurthle cells with nuclear features suggestive of malignancy is a characteristic finding in this type of carcinoma.

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