Adult Health Nursing Study Guide Answers

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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 description of multiple flesh-colored papular lesions with a central dell that tend to bleed upon minor trauma and have been increasing in number over time is characteristic of basal cell carcinoma. Basal cell carcinoma is the most common type of skin cancer and typically presents as pearly or flesh-colored papules with telangiectasias (tiny blood vessels) and a characteristic central dell or ulceration. This type of skin cancer often occurs on sun-exposed areas like the face and trunk and can manifest as slow-growing lesions that may bleed easily with minor trauma. In contrast, squamous cell carcinoma typically presents as a scaly or crusted lesion, seborrheic keratosis is a benign skin growth with a waxy, stuck-on appearance, and actinic keratosis is a precancerous lesion characterized by rough, scaly patches on sun-exposed areas.

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In problem solving the head nurse must know what is the MAJOR characteristic of negotiation?

  • A. Be positive in your approach since optimism gives further favorable results.
  • B. Harmony is possible even when strategies are not well planned.
  • C. It is not important to get anything in writing since the truth will prevail.
  • D. Resources tend to involve too many individuals in decision-making process .
Correct Answer: A

Rationale: The MAJOR characteristic of negotiation is being positive in your approach since optimism typically leads to more favorable results. Negotiation involves communication, compromise, and finding mutually beneficial solutions. Approaching negotiations with a positive mindset can help in maintaining a constructive atmosphere, enhancing communication, and increasing the likelihood of reaching a successful agreement. Being positive can also contribute to building relationships and trust with the other party, leading to better long-term outcomes.

In a conscious trauma patient with a suspected head injury, which of the following actions is appropriate?

  • A. Applying direct pressure to the wound.
  • B. Administering aspirin for pain relief.
  • C. Maintaining cervical spine immobilization.
  • D. Assessing pupil reaction to light.
Correct Answer: C

Rationale: In a conscious trauma patient with a suspected head injury, maintaining cervical spine immobilization is crucial. The presence of a head injury raises concerns for potential concomitant cervical spine injury. Therefore, it is vital to prevent any movement of the cervical spine to avoid exacerbating a potential spinal cord injury. Maintaining immobilization involves stabilizing the patient's head and neck in a neutral position until appropriate imaging studies can assess the extent of any spinal injury. This action helps prevent further harm and ensures the safety of the patient during assessment and management of their injuries.

If more than one vaccine is given, the following guidelines should be observed, EXCEPT.

  • A. Do not give more than one dose of the same vaccine in one session.
  • B. Do not use the same arm or leg for more than one injection.
  • C. Give doses of the same vaccine at the correct intervals.
  • D. Use the same syringe and needle in administering two vaccines.
Correct Answer: D

Rationale: It is NOT recommended to use the same syringe and needle in administering two different vaccines. This is to prevent contamination or mixing of different vaccines, which could potentially affect their effectiveness or pose a risk to the individual receiving the vaccines. It is important to use separate syringes and needles for each vaccine to ensure proper administration and prevent any adverse reactions.

When collecting evidence from a rape victim, the victim's clothing is removed and placed in a

  • A. paper bag .
  • B. Plastic bag
  • C. Ziploc bag
  • D. Trash bag
Correct Answer: A

Rationale: When collecting evidence from a rape victim, it is important to handle the victim's clothing properly to preserve any potential evidence. The preferred method is to remove the clothing and place them in a paper bag. Paper bags are used in order to prevent the alteration or degradation of any DNA evidence that may be present on the clothing. Paper bags allow the clothing to breathe and prevent the growth of mold or other contaminants that can occur in plastic bags or trash bags. Additionally, paper bags help preserve trace evidence such as fibers or hairs that may be crucial in the investigation of the case. It is essential to handle and store the clothing correctly to maintain the integrity of the evidence for the investigation and potential prosecution.

A woman in active labor experiences frequent and intense uterine contractions with minimal rest intervals, leading to maternal fatigue and decreased fetal oxygenation. What maternal condition should the nurse assess for that may contribute to this abnormal labor pattern?

  • A. Maternal dehydration
  • B. Uterine hyperstimulation
  • C. Pelvic outlet obstruction
  • D. Maternal exhaustion
Correct Answer: B

Rationale: Uterine hyperstimulation, also known as tachysystole, is a condition characterized by frequent and intense uterine contractions with minimal rest intervals. This can lead to maternal fatigue and decreased fetal oxygenation due to the insufficient time for the uterus to relax and refill with oxygenated blood between contractions. Uterine hyperstimulation can be caused by various factors such as excessive use of uterotonics (oxytocin or prostaglandins), improper labor induction techniques, or maternal conditions like previous uterine surgery. It is essential for the nurse to assess for signs of uterine hyperstimulation and take appropriate interventions to prevent potential complications for both the mother and the baby.

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