Adult Health Nursing Answer Key

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A pregnant woman presents with severe lower abdominal pain and vaginal bleeding. On examination, cervical motion tenderness and unilateral adnexal tenderness are noted, along with an adnexal mass on the affected side. Which of the following conditions is the most likely cause of these symptoms?

  • A. Ectopic pregnancy
  • B. Pelvic inflammatory disease
  • C. Placenta previa
  • D. Ovarian torsion
Correct Answer: A

Rationale: The clinical presentation of severe lower abdominal pain and vaginal bleeding in a pregnant woman, along with cervical motion tenderness, unilateral adnexal tenderness, and an adnexal mass on the affected side, is highly concerning for an ectopic pregnancy. Ectopic pregnancy occurs when a fertilized egg implants outside the uterus, most commonly in the fallopian tube. The presence of an adnexal mass and tenderness on one side is indicative of potential tubal involvement and can mimic symptoms of pelvic inflammatory disease. Prompt evaluation and management are crucial in ectopic pregnancy to prevent life-threatening complications associated with rupture of the fallopian tube.

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A patient presents with sudden onset of severe chest pain radiating to the back, hypotension, and a widened mediastinum on chest X-ray. Which cardiovascular disorder is most likely responsible for these symptoms?

  • A. Stable angina
  • B. Unstable angina
  • C. Acute myocardial infarction
  • D. Aortic dissection
Correct Answer: D

Rationale: #NAME?

Nurse Selma is preparing to administer ofloxacin eardrop on Catherine per Doctor's order. She needs to hold the bottle with her hands to warm up the solution to prevent dizziness for

  • A. 5-6 minutes
  • B. 1 to 2 minutes
  • C. 3-4 minutes
  • D. 6-7 minutes
Correct Answer: B

Rationale: Warming up ofloxacin eardrops before administering is done to prevent dizziness, which can occur if a cold solution is placed in the ear. Holding the bottle with hands for about 1 to 2 minutes is usually sufficient to warm up the solution to a comfortable temperature for the patient. Warming the solution for too long, such as 5-6 minutes, may not be necessary and could potentially waste time. So, the correct duration for warming up ofloxacin eardrops is 1 to 2 minutes.

A patient presents with gradual-onset memory loss, confusion, and difficulty with complex tasks such as managing finances and planning. Over time, the patient develops disorientation to time and place and requires assistance with activities of daily living. Which of the following neurological conditions is most likely responsible for these symptoms?

  • A. Alzheimer's disease
  • B. Parkinson's disease
  • C. Huntington's disease
  • D. Frontotemporal dementia
Correct Answer: A

Rationale: The patient's presentation of gradual-onset memory loss, confusion, difficulty with complex tasks, disorientation, and functional decline are all classic features of Alzheimer's disease. Alzheimer's disease is a progressive neurodegenerative disorder characterized by the accumulation of abnormal protein deposits in the brain, leading to widespread neuronal damage and cognitive decline. As the disease progresses, patients typically experience worsening memory loss, cognitive impairment, and deficits in activities of daily living, ultimately requiring full-time care and assistance. Other neurodegenerative diseases such as Parkinson's disease, Huntington's disease, and frontotemporal dementia may present with cognitive impairment and behavioral changes, but the specific constellation of symptoms described in the case is most indicative of Alzheimer's disease.

In the assessing the health condition of the preganant patient, Nurse Vera should focus on the _________.

  • A. last menstrual period
  • B. number of days of menstruation
  • C. age of patient during menarche
  • D. amount of menstrual flow
Correct Answer: A

Rationale: Nurse Vera should focus on the last menstrual period when assessing the health condition of the pregnant patient because it is crucial for determining the estimated due date of the pregnancy. Knowing the date of the last menstrual period allows healthcare providers to calculate the gestational age of the fetus, monitor the progress of the pregnancy, and identify any potential issues or complications that may arise. Additionally, the last menstrual period is necessary for accurate dating of the pregnancy and scheduling prenatal care visits and screenings. By focusing on the last menstrual period, Nurse Vera can gather important information that will guide the management and care of the pregnant patient.

The purpose why the head nurse asked Nurse Rosie to submit an IR is to ______.

  • A. note patterns of incidences in the same unit
  • B. place it in Nurse Rosie's 201 file
  • C. document immediately the incident
  • D. evaluate Nurse Rosie's performance
Correct Answer: A

Rationale: The purpose of asking Nurse Rosie to submit an Incident Report (IR) is most likely to note patterns of incidences in the same unit. Incident reports are essential tools in healthcare settings to track and analyze unexpected events, errors, or situations that may impact patient care and safety. By collecting and reviewing incident reports, the head nurse can identify trends, patterns, or commonalities in the occurrences within the unit. This information allows for targeted interventions, improvements in practices, and enhanced patient safety. Therefore, asking Nurse Rosie to submit an IR would serve the purpose of noting patterns of incidences in the same unit for proactive and quality care delivery.

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