Adult Health Nursing Answer Key

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A patient presents with multiple, flesh-colored, papular lesions with a central dell on the face and trunk. The lesions have a tendency to bleed upon minor trauma and have been increasing in number over time. Which of the following conditions is most likely responsible for this presentation?

  • A. Basal cell carcinoma
  • B. Squamous cell carcinoma
  • C. Seborrheic keratosis
  • D. Actinic keratosis
Correct Answer: A

Rationale: The presentation described in the question is classic for basal cell carcinoma (BCC). BCC typically presents as multiple, flesh-colored, papular lesions with a central dell (resembling a pearl-like appearance) on sun-exposed areas such as the face and trunk. These lesions are known to bleed easily upon minor trauma and tend to increase in number over time. BCC is the most common type of skin cancer, often triggered by sun exposure. On the other hand, seborrheic keratosis (choice C) presents as benign, pigmented, stuck-on, waxy, or warty lesions with a rough surface, true bumpy appearance. Squamous cell carcinoma (choice B) usually presents as a scaly, erythematous, rapidly growing nodule, ulcer, or plaque. Actinic keratosis (choice D) presents as rough, scaly patches on sun-exposed areas that can progress to

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One of the committee members raised the question on how to make an abstract. The question was followed by how many words are required in an abstract should (APA) style be followed.? What is the CORRECT answer?

  • A. 450-550
  • B. 150-250
  • C. 250 -350
  • D. 350-450
Correct Answer: B

Rationale: When following the APA style, the recommended word count for an abstract is typically between 150 to 250 words. An abstract should serve as a concise summary of the main points of a research paper, providing the reader with a preview of the content without going into excessive detail. Keeping the abstract within the specified word range ensures that it effectively captures the essence of the paper while remaining clear and succinct.

A postpartum client reports persistent, severe perineal pain despite analgesic medication. On assessment, the nurse observes ecchymosis and swelling of the perineum. Which nursing action is most appropriate?

  • A. Applying ice packs to the perineum for pain relief
  • B. Encouraging the client to sit on a donut cushion
  • C. Notifying the healthcare provider immediately
  • D. Administering additional analgesic medication
Correct Answer: C

Rationale: The presence of ecchymosis (bruising) and significant swelling in the perineum despite analgesic medication suggests a potential complication such as a hematoma. A hematoma is a collection of blood that can occur due to trauma or during childbirth. It is important to notify the healthcare provider immediately so that further assessment and interventions, such as drainage of the hematoma, can be initiated promptly to prevent complications and alleviate the client's pain. Applying ice packs or encouraging the client to sit on a donut cushion may provide temporary relief but will not address the underlying issue of a potentially serious hematoma. Administering additional analgesic medication may not be effective in this case if the pain is primarily due to the hematoma. Prompt notification of the healthcare provider is crucial for proper management of this situation.

The staff assigned to check the fire extinguisher failed to monitor the assigned equipment. The following statements are "whereabouts" of true, EXCEPT

  • A. all employees are lazy
  • B. monitoring staff is important
  • C. not all staff are diligent in their tasks
  • D. two errors added together can be potentially devastating
Correct Answer: A

Rationale: The statement "all employees are lazy " is not a correct assertion. It is a generalization that is unfair to make about all employees. It is incorrect to assume that all employees are lazy based on the failure of a certain staff member to monitor the fire extinguisher. Making blanket statements like this can lead to further misunderstandings and negativity in the workplace. The focus should be on individual accountability, proper training, and clear communication to ensure that tasks are being diligently carried out.

A patient presents with irritability, muscle weakness, tremors, and weight loss despite increased appetite. Laboratory tests reveal elevated serum thyroid hormone levels and suppressed thyroid-stimulating hormone (TSH) levels. Which endocrine disorder is most likely responsible for these symptoms?

  • A. Hyperthyroidism
  • B. Hypothyroidism
  • C. Diabetes mellitus
  • D. Cushing's syndrome
Correct Answer: A

Rationale: The symptoms of irritability, muscle weakness, tremors, weight loss despite increased appetite, along with elevated serum thyroid hormone levels and suppressed TSH levels, are indicative of hyperthyroidism. In hyperthyroidism, the thyroid gland produces an excess amount of thyroid hormone, leading to an overactive metabolism. This results in symptoms such as weight loss, tremors, irritability, and muscle weakness. The elevated levels of thyroid hormone are detected in the laboratory tests, along with low TSH levels due to negative feedback regulation. Therefore, the most likely endocrine disorder responsible for these symptoms is hyperthyroidism.

The labor progress and the physician performed amniotomy. Nurse Hope should FIRST assess tor _______.

  • A. bladder distention
  • B. maternal blood pressure
  • C. cervical dilatation
  • D. fetal heart rate (FHR) pattern
Correct Answer: D

Rationale: Following an amniotomy procedure during labor, Nurse Hope's priority should be to assess the fetal heart rate (FHR) pattern. This assessment is crucial to ensure the well-being and safety of the fetus. Changes in the FHR can provide valuable information about fetal distress or complications, allowing for timely interventions if needed. Monitoring the FHR pattern is a standard practice during labor and delivery to track the fetus's response to the changes in uterine activity. Therefore, assessing the FHR pattern should be the first priority after a labor progress and amniotomy.

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