Adult Health Nursing Study Guide Answers

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A patient presents with recurrent episodes of postnasal drip, chronic cough, and halitosis. Nasal endoscopy reveals a foul-smelling, yellowish discharge draining from the middle meatus. Which of the following conditions is most likely responsible for this presentation?

  • A. Chronic rhinosinusitis with nasal polyps
  • B. Allergic rhinitis
  • C. Nasal vestibulitis
  • D. Adenoid hypertrophy
Correct Answer: A

Rationale: The patient's presentation of recurrent episodes of postnasal drip, chronic cough, halitosis, and foul-smelling, yellowish discharge from the middle meatus is highly suggestive of chronic rhinosinusitis. The presence of nasal polyps further supports this diagnosis. Chronic rhinosinusitis with nasal polyps is characterized by inflammation of the paranasal sinuses, leading to symptoms such as nasal congestion, postnasal drip, cough, and a reduced sense of smell. The yellowish discharge and foul odor are typical findings in cases of chronic rhinosinusitis with secondary bacterial infection. Nasal endoscopy may reveal edematous nasal mucosa and polyps obstructing the middle meatus, contributing to the symptoms described by the patient. Management typically involves a combination of medical therapies such as intranasal corticosteroids, saline irrigation, and antibiotics, and in some cases, surgical intervention

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. The patient with nephrotic syndrome is ordered corticosteroids. Who of the following are NOT ALLOWED in the patient's

  • A. Parents with diabetes.
  • B. Relatives with upper respiratory tract infection.
  • C. Visitors with mild asthma.
  • D. Personnel with allergy.
Correct Answer: A

Rationale: Patients with nephrotic syndrome who are ordered corticosteroids need to avoid close contact with individuals who have infections or illnesses, as corticosteroids can suppress the immune system and increase the risk of infections. Therefore, it is important to prioritize the safety and well-being of the patient by minimizing potential sources of infection. While diabetes itself does not pose a direct risk to the patient with nephrotic syndrome, individuals with diabetes may have a compromised immune system or be at higher risk for infections, which could potentially be transmitted to the patient. This precaution helps to minimize the risk of infection and maximize the effectiveness of the treatment for nephrotic syndrome.

Signs such as using tissues to doorknobs develop because the patient is ________.

  • A. unconsciously controlling unacceptable impulses or feelings
  • B. Listening to voices that tell her that doorknobs are unclean
  • C. consciously using this method of punishing herself
  • D. fulfilling a need to punish others procedure by carrying out annoying
Correct Answer: A

Rationale: Signs such as using tissues to doorknobs suggest that the patient is unconsciously controlling unacceptable impulses or feelings. This behavior falls under the category of defense mechanisms, specifically displacement, where the individual redirects their emotions from a threatening target to a safer one. In this case, the patient may be experiencing anxiety or fear related to contamination or germs, leading them to use tissues to avoid touching doorknobs directly. It is a way for the patient to manage their underlying emotions, albeit unconsciously, through this compulsive behavior.

While preparing the surgical instruments for sterilization, the nurse notices visible residue on some of the instruments. What action should the nurse take?

  • A. Re-sterilize the instruments
  • B. Use the instruments for the procedure as they are
  • C. Document the findings in the instrument log
  • D. Notify the sterile processing department
Correct Answer: A

Rationale: If visible residue is noticed on the surgical instruments, it is crucial to re-sterilize them before using them for any procedure. Visible residue may indicate that the instruments are not sterile and could potentially introduce contaminants into the patient during the procedure, leading to infection or other complications. It is essential to maintain the highest standards of cleanliness and sterility in healthcare settings to ensure patient safety. Therefore, the nurse should take immediate action to re-sterilize the instruments before proceeding with any surgical procedure.

The patient asks what is a normal thyroid state? The best response is __________.

  • A. Euthyroid
  • B. Hyperthyroid
  • C. Parathyroid
  • D. Panthroid
Correct Answer: A

Rationale: A normal thyroid state is referred to as euthyroid, which means the thyroid gland is functioning within normal parameters and the levels of thyroid hormones in the body are balanced. In contrast, hyperthyroid refers to an overactive thyroid gland, causing excessive production of thyroid hormones, while parathyroid is a different gland responsible for regulating calcium levels in the body. Panthroid is not a recognized medical term related to thyroid function. Therefore, the best response to the patient's question about the normal thyroid state is "Euthyroid."

A primigravida at 39 weeks gestation presents to the labor and delivery unit with contractions every 5 minutes, lasting 45 seconds each. On examination, her cervix is dilated to 3 cm. What is the appropriate nursing intervention?

  • A. Encourage the mother to walk to facilitate labor progression.
  • B. Administer oxytocin to augment labor.
  • C. Prepare for cesarean section.
  • D. Encourage relaxation techniques to manage pain.
Correct Answer: A

Rationale: The appropriate nursing intervention in this case is to encourage the mother to walk to facilitate labor progression. The patient is in early labor with contractions every 5 minutes, lasting 45 seconds each, and her cervix is dilated to 3 cm. Encouraging the mother to walk can help gravity assist the descent of the baby and promote cervical dilation. Walking can also help alleviate some discomfort and encourage labor progression. It is important to promote natural, non-invasive methods to support the progress of labor before considering medical interventions such as oxytocin or cesarean section. Relaxation techniques can also be beneficial in managing pain during labor.

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