Adult Health Nursing Quizlet Final

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A patient with a history of chronic kidney disease presents with weakness, anorexia, and confusion. Laboratory tests reveal severe anemia, low reticulocyte count, elevated serum creatinine, and decreased erythropoietin levels. Which of the following conditions is most likely to cause these findings?

  • A. Anemia of chronic disease
  • B. Hemolytic uremic syndrome (HUS)
  • C. Autoimmune hemolytic anemia (AIHA)
  • D. Renal failure-associated anemia
Correct Answer: D

Rationale: The clinical presentation of a patient with chronic kidney disease (CKD) presenting with weakness, anorexia, confusion, severe anemia, low reticulocyte count, elevated serum creatinine, and decreased erythropoietin levels is most consistent with renal failure-associated anemia. In CKD, the kidneys are unable to produce adequate amounts of erythropoietin, a hormone responsible for stimulating red blood cell production in the bone marrow. The decreased erythropoietin levels lead to a state of anemia, characterized by low hemoglobin levels and subsequent symptoms of fatigue and weakness. The anemia in renal failure is typically normocytic and normochromic. Additionally, the elevated serum creatinine in this patient is a hallmark of kidney dysfunction.

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What is the first step in the management of a chemical splash to the eyes?

  • A. Irrigate the eyes with clean water.
  • B. Instill antibiotic eye drops.
  • C. Cover both eyes with a sterile dressing.
  • D. Assess visual acuity.
Correct Answer: A

Rationale: The first step in the management of a chemical splash to the eyes is to irrigate the eyes with clean water. Flushing the affected eye with water helps to remove the chemical and minimize any potential injury. It is important to continue irrigation for at least 15-20 minutes to ensure thorough removal of the chemical. This prompt action can help prevent further damage to the eye and surrounding tissue. It is crucial to remember not to delay irrigation to seek medical advice first, as immediate irrigation is vital in such situations. After irrigating the eyes, further assessment and treatment can be carried out based on the severity of the injury.

A postpartum client reports severe perineal pain and difficulty passing stools following a vaginal delivery. Which nursing intervention should be implemented?

  • A. Administering a stool softener as ordered
  • B. Encouraging the client to refrain from defecation until pain subsides
  • C. Applying ice packs to the perineum for pain relief
  • D. Providing education on proper perineal hygiene
Correct Answer: A

Rationale: Administering a stool softener as ordered is the most appropriate nursing intervention for a postpartum client experiencing severe perineal pain and difficulty passing stools following a vaginal delivery. Stool softeners help to soften the stool, making it easier for the client to pass without straining, which can exacerbate perineal pain. It is important to follow the healthcare provider's orders when administering medications to ensure proper dosing and effectiveness. Encouraging the client to refrain from defecation may lead to constipation and worsen the situation. Applying ice packs to the perineum can provide temporary pain relief, but addressing the underlying issue of constipation with a stool softener is more effective in the long term. Providing education on proper perineal hygiene is important for overall postpartum care, but addressing the immediate issue of constipation with a stool softener takes precedence in this scenario.

Nurse Pat promised to a post- surgical patient, that she would come back to assist in his ambulation after carrying out the physician's order. This follows the principle of

  • A. beneficence
  • B. justice
  • C. autonomy
  • D. fidelity
Correct Answer: D

Rationale: Fidelity is a principle of ethics that relates to being faithful or loyal to one's commitments and responsibilities. When Nurse Pat promises to assist the post-surgical patient with ambulation after carrying out the physician's order, she is demonstrating fidelity by honoring her commitment to the patient. This principle highlights the importance of keeping promises, being reliable, and maintaining trust in the nurse-patient relationship.

Which of the following conditions is characterized by the presence of multiple fluid-filled sacs within the ovaries and is associated with menstrual irregularities and hyperandrogenism?

  • A. Polycystic ovary syndrome (PCOS)
  • B. Ovarian torsion
  • C. Ovarian cyst rupture
  • D. Ovarian cancer
Correct Answer: A

Rationale: Polycystic ovary syndrome (PCOS) is a common endocrine disorder in women of reproductive age. It is characterized by the presence of multiple fluid-filled sacs (cysts) within the ovaries, which can be visualized on ultrasound. Women with PCOS often experience menstrual irregularities such as irregular periods or no periods, as well as symptoms of hyperandrogenism like hirsutism (excessive hair growth) and acne. Other common features of PCOS include insulin resistance and obesity. It is important to note that not all women with PCOS will have ovarian cysts, but the presence of multiple cysts is a common finding in this condition.

Ella states'I will hang my self' this is a manifestation of:

  • A. Denial
  • B. Suicidal intent
  • C. Suicidal threat
  • D. Paranoia.
Correct Answer: B

Rationale: Ella's statement "I will hang myself" directly indicates a desire and intent to commit suicide. This is classified as a suicidal intent, which is a serious concern that requires immediate attention and intervention. It is crucial to take any mention or indication of suicide seriously and seek help from mental health professionals or crisis intervention services.

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