Adult Health Nursing Answer Key

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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

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A patient presents with a yellowish-white spot on the cornea, surrounded by a ring of inflammation. Slit-lamp examination reveals branching, filamentous opacities extending from the corneal lesion. Which of the following conditions is most likely responsible for this presentation?

  • A. Herpes simplex keratitis
  • B. Bacterial keratitis
  • C. Fungal keratitis
  • D. Acanthamoeba keratitis
Correct Answer: C

Rationale: The described clinical presentation of a yellowish-white spot on the cornea with a ring of inflammation, along with branching, filamentous opacities extending from the corneal lesion, is highly suggestive of fungal keratitis. Fungal keratitis is commonly caused by filamentous fungi such as Fusarium and Aspergillus species. The characteristic finding of branching, filamentous opacities seen on slit-lamp examination is classic for fungal infections of the cornea. It is important to promptly diagnose and treat fungal keratitis since delayed or inadequate management can result in vision-threatening complications.

A woman in active labor is experiencing umbilical cord prolapse. What is the priority nursing action?

  • A. Elevating the mother's hips to relieve pressure on the cord
  • B. Preparing for immediate cesarean section
  • C. Administering intravenous fluids rapidly
  • D. Applying external fetal monitoring to assess fetal heart rate
Correct Answer: B

Rationale: In the case of umbilical cord prolapse, the priority nursing action is to prepare for an immediate cesarean section. Umbilical cord prolapse is a serious obstetric emergency where the umbilical cord slips through the cervix ahead of the presenting part of the fetus. This can lead to compression of the cord, compromising fetal blood flow and oxygenation. Immediate delivery via cesarean section is necessary in order to prevent fetal hypoxia and avoid potential complications such as brain damage or death. Elevating the mother's hips or administering intravenous fluids rapidly may be interventions done in conjunction with preparing for a cesarean section, but the priority remains expedited delivery of the baby. Applying external fetal monitoring is not the most appropriate action in this emergency situation.

A client has undergone a lymph node biopsy. The nurse anticipates that the report will reveal which result if the client has Hodgkin's Lymphoma?

  • A. Reed-Sternberg cells
  • B. Philadelphia chromosome
  • C. Epstein-barr virus
  • D. Herpes simplex virus
Correct Answer: A

Rationale: Reed-Sternberg cells are large, abnormal lymphocytes that are characteristic of Hodgkin's Lymphoma. They are typically found in the affected lymph nodes of individuals with Hodgkin's Lymphoma when examined under a microscope. Identifying Reed-Sternberg cells in a lymph node biopsy is a key diagnostic feature of Hodgkin's Lymphoma. This distinguishes Hodgkin's Lymphoma from other types of lymphomas that do not have Reed-Sternberg cells.

She plans to interview the Psyche Nurse Manager about the patient safety practices of the nurses. What type of sampling includes those who happen to be in the conference room where the activity is scheduled?

  • A. Random
  • B. convenience
  • C. Purposive
  • D. Quota
Correct Answer: B

Rationale: Convenience sampling involves selecting participants who are readily available or easy to access. In this scenario, choosing to interview nurses who happen to be in the conference room where the activity is scheduled falls under convenience sampling as they are easily accessible at that moment. While convenience sampling may be convenient, it may introduce bias and may not represent the entire population accurately.

A patient with terminal cancer is experiencing severe pain despite receiving analgesics. Which intervention by the palliative nurse is most appropriate?

  • A. Increase the dose of analgesics.
  • B. Administer a different type of analgesic.
  • C. Recommend non-pharmacological pain management techniques.
  • D. Consult with a pain management specialist.
Correct Answer: D

Rationale: In a situation where a patient with terminal cancer is experiencing severe pain despite receiving analgesics, consulting with a pain management specialist is the most appropriate intervention. Pain management specialists have expertise in managing complex pain situations, especially in cases of terminal illness where pain control is crucial for improving quality of life. The specialist can review the current pain management plan, suggest alternative or adjunct therapies, adjust medication dosages, or explore different types of analgesics to optimize pain relief for the patient. Collaborating with a pain management specialist can help ensure the patient receives the most effective and personalized pain management approach tailored to their specific needs. Increasing the dose of analgesics, administering a different type of analgesic, or recommending non-pharmacological techniques may be appropriate interventions but should be guided by a specialist to ensure safe and effective pain management in a palliative care setting.

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