Adult Health Nursing Answer Key

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A postpartum client is breastfeeding and expresses discomfort during feedings due to sore nipples. What nursing intervention should be prioritized to alleviate nipple soreness?

  • A. Educating the client on proper latch technique
  • B. Recommending the use of nipple shields during feedings
  • C. Applying lanolin cream to the nipples after each feeding
  • D. Encouraging the use of breast pumps instead of direct breastfeeding
Correct Answer: A

Rationale: Proper latch technique is the most important nursing intervention to alleviate nipple soreness in a breastfeeding client. When a baby latches on correctly, it helps prevent nipple trauma and soreness. Educating the client on how to achieve a proper latch, such as ensuring the baby's mouth covers both the nipple and areola, can significantly reduce discomfort during feedings. Improving the latch can also enhance milk transfer, leading to better breastfeeding outcomes for both the mother and baby. While lanolin cream (choice C) can provide some relief for sore nipples, addressing the root cause by correcting the latch is crucial for long-term comfort and successful breastfeeding. Using nipple shields (choice B) or encouraging the use of breast pumps (choice D) should not be the first line of intervention when addressing sore nipples, as they do not address the underlying issue of latch technique.

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A postpartum client presents with persistent, severe abdominal pain, distention, and absent bowel sounds. Which nursing action is most appropriate?

  • A. Encouraging the client to ambulate to promote bowel function
  • B. Providing a heating pad to alleviate abdominal discomfort
  • C. Notifying the healthcare provider immediately
  • D. Administering a laxative to promote bowel evacuation
Correct Answer: C

Rationale: The most appropriate nursing action in this situation is to notify the healthcare provider immediately. The symptoms the postpartum client is experiencing - persistent, severe abdominal pain, distention, and absent bowel sounds - are concerning and could indicate a serious underlying issue such as bowel obstruction or other complications. Prompt communication with the healthcare provider is crucial to ensure the client receives the necessary assessment, intervention, and treatment. Encouraging ambulation, providing a heating pad, or administering a laxative are not appropriate actions in this case without first consulting with the healthcare provider due to the severity and potential complexity of the client's symptoms.

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.

Sexual dysfunctions 1ike impotence, erectile dysfunction, and lack of libido are likely possibilities in what, prostatic surgery?

  • A. Suprapubic prostatectomy
  • B. Transurethral resection of the prostate
  • C. Laparoscopic prostatectomy
  • D. Perineal prostatectomy
Correct Answer: B

Rationale: Sexual dysfunctions like impotence, erectile dysfunction, and lack of libido are common complications following prostatic surgery. Among the options provided, transurethral resection of the prostate (TURP) is associated with a higher risk of these sexual dysfunctions. This is because during TURP, the surgical procedure may damage nerves and blood vessels that are crucial for sexual function, leading to impotence, erectile dysfunction, and decreased libido postoperatively.

Which of the following statements accurately describes the role of major histocompatibility complex (MHC) molecules in antigen presentation?

  • A. MHC class I molecules present exogenous antigens to CD4+ T cells.
  • B. MHC class I molecules present endogenous antigens to CD8+ T cells.
  • C. MHC class II molecules present endogenous antigens to CD4+ T cells.
  • D. MHC class II molecules present exogenous antigens to CD8+ T cells.
Correct Answer: B

Rationale: Major histocompatibility complex (MHC) class I molecules are responsible for presenting endogenous antigens, such as viral or intracellular proteins, to CD8+ T cells. These antigens are derived from within the cell, either synthesized within the cell itself or taken up from the cytoplasm. CD8+ T cells, also known as cytotoxic T cells, recognize antigens presented by MHC class I molecules and play a key role in cell-mediated immunity by destroying infected or abnormal cells.

After 3 years being assigned in the Operating Room, Merle in interested to actively join which appropriate professional organization?

  • A. ORNAP
  • B. ADPCN
  • C. NLGN
  • D. APO
Correct Answer: A

Rationale: ORNAP stands for Operating Room Nurses Association of the Philippines. As Merle has been assigned in the Operating Room for 3 years and is interested in actively joining a professional organization related to this field, ORNAP would be the most appropriate choice. ORNAP focuses on promoting excellence in perioperative nursing practice through education, research, and collaboration. By joining ORNAP, Merle can further enhance her knowledge and skills in the Operating Room setting, as well as network with other professionals in the same field.

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