Adult Health Nursing Study Guide Answers

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A patient with advanced dementia is bedbound and at risk of developing pressure ulcers. What intervention should the palliative nurse prioritize to prevent pressure ulcer formation?

  • A. Turn the patient every 2 hours to relieve pressure on bony prominences.
  • B. Apply barrier creams or moisture barriers to protect vulnerable skin areas.
  • C. Use pressure-relieving support surfaces, such as specialized mattresses or cushions.
  • D. Administer prophylactic antibiotics to prevent infection in at-risk skin areas.
Correct Answer: C

Rationale: The most effective intervention to prevent pressure ulcers in bedbound patients at risk, such as those with advanced dementia, is to use pressure-relieving support surfaces like specialized mattresses or cushions. These surfaces help distribute the pressure evenly, reducing the risk of pressure ulcer formation on bony prominences. Turning the patient every 2 hours (choice A) can also help relieve pressure, but it may not be sufficient to prevent pressure ulcers in high-risk individuals. Applying barrier creams or moisture barriers (choice B) can help protect the skin but may not address the underlying issue of pressure on vulnerable areas. Administering prophylactic antibiotics (choice D) is not recommended for preventing pressure ulcers as it does not address the root cause of the problem and can lead to antibiotic resistance. Therefore, the priority intervention should be to use pressure-relieving support surfaces to minimize the risk of pressure ulcers in

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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 characteristic of anterior uveitis. Anterior uveitis is inflammation of the iris and ciliary body in the eye. Patients typically present with symptoms such as redness, pain, and photophobia. Slit-lamp examination findings include ciliary injection (redness and engorgement of blood vessels in the ciliary body), corneal edema (swelling of the cornea), and a mid-dilated pupil with a fixed reaction to light due to involvement of the iris muscles. These features differentiate anterior uveitis from other conditions. Treatment of anterior uveitis may involve topical steroids and cycloplegics to reduce inflammation and alleviate symptoms.

Patient Presley who is ordered for diagnostic pelvic ultrasound asks what preparation she' 11 take. Appropriate preparations for this procedure include_________.

  • A. explanation of the procedure
  • B. NPO 6 hours before
  • C. informed consent
  • D. voiding
Correct Answer: D

Rationale: For a diagnostic pelvic ultrasound, one important preparation is to have the patient void or empty their bladder before the procedure. This allows for better visualization of the pelvic organs and structures during the ultrasound scan. A full bladder can obstruct the view and make it difficult to obtain accurate images. Therefore, it is essential for the patient to follow instructions to empty their bladder before the pelvic ultrasound to ensure the best results.

Which of the following is not a characteristic of quality improvement that the medical director is interested in?

  • A. The leader is the empowerer
  • B. Problem-solving is by everyone
  • C. The employees are treated as customers
  • D. Reacts to correct or bad situation
Correct Answer: D

Rationale: Quality improvement focuses on proactive measures rather than reactive responses. The medical director would be more interested in establishing processes and systems that prevent issues from occurring in the first place, rather than just reacting to problems as they arise. Continuous improvement involves identifying problems, analyzing root causes, and implementing long-term solutions to prevent the issues from recurring. Therefore, reacting to correct or bad situations is not a characteristic of quality improvement that the medical director would prioritize.

While preparing the surgical instruments for sterilization, the nurse notices that the autoclave is not reaching the required temperature. What should the nurse do?

  • A. Document the issue in the equipment log and continue with sterilization
  • B. Adjust the settings on the autoclave to increase the temperature
  • C. Notify the sterile processing department and request maintenance
  • D. Use an alternative method of sterilization for the instruments
Correct Answer: C

Rationale: It is crucial to ensure that the autoclave is functioning properly to achieve proper sterilization of surgical instruments. If the autoclave is not reaching the required temperature, it signifies a technical issue that needs to be addressed promptly. The nurse should notify the sterile processing department immediately and request maintenance to investigate and resolve the problem. Continuing with sterilization without addressing the temperature issue can compromise the effectiveness of sterilization and pose a risk of infection to patients. Adjusting the settings on the autoclave or using an alternative method of sterilization are not appropriate actions in this situation.

Which of the following statements accurately describes the role of natural killer (NK) cells in the immune response?

  • A. NK cells directly kill virus-infected cells and tumor cells.
  • B. NK cells produce antibodies against pathogens.
  • C. NK cells present antigens to T cells to initiate adaptive immunity.
  • D. NK cells release cytokines to recruit other immune cells to the site of infection.
Correct Answer: A

Rationale: Natural killer (NK) cells play a vital role in the innate immune response by identifying and eliminating virus-infected cells, as well as tumor cells, without the need for prior exposure or activation. NK cells are able to detect abnormal cells by recognizing changes in the cell surface molecules, such as downregulation of MHC class I molecules. Once activated, NK cells release cytotoxic granules containing perforin and granzyme, leading to the destruction of the target cell. This direct killing mechanism is crucial for controlling viral infections and preventing the development of tumors. NK cells do not produce antibodies (option B), present antigens to T cells (option C), or release cytokines to recruit other immune cells (option D) as their primary function in the immune response.

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