Adult Health Nursing Answer Key

Correct Answer: A

Rationale: The clinical presentation of heavy menstrual bleeding, iron deficiency anemia, an enlarged uterus, and irregularly shaped masses palpated on pelvic examination is most indicative of leiomyomas, also known as uterine fibroids. Leiomyomas are benign smooth muscle tumors that commonly occur in women of reproductive age. They can lead to heavy menstrual bleeding and iron deficiency anemia due to their size and location within the uterus. On pelvic examination, leiomyomas can be felt as irregularly shaped masses within the uterine wall. This presentation is classic for leiomyomas and distinguishes them from conditions such as endometrial polyps, endometrial hyperplasia, and adenomyosis.

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.

Correct Answer: D

Rationale: Patient Sonia, who has hypothyroidism, would benefit from treatment with levothyroxine. Levothyroxine is a synthetic form of the thyroid hormone thyroxine (T4) and is commonly prescribed to replace the deficient thyroid hormone in patients with hypothyroidism. It helps restore the thyroid hormone levels in the body, relieving symptoms such as fatigue, weight gain, and cold intolerance that are characteristic of hypothyroidism. Propranolol is a beta-blocker used for conditions like hypertension, anxiety, and migraines; iron pills are used to treat iron deficiency anemia; and iodine supplementation is not typically used in the treatment of hypothyroidism unless it is due to iodine deficiency.

Correct Answer: B

Rationale: In this scenario, the palliative nurse should prioritize encouraging the patient to conserve energy and avoid unnecessary activities (Option B). End-stage heart failure can lead to severe fatigue and limited mobility, making it essential for the patient to conserve energy to prevent exacerbating symptoms and improve quality of life. Engaging in physical therapy (Option A) may not be suitable for a patient experiencing severe fatigue, as it can further drain energy reserves. Prescribing stimulant medications (Option C) may have limited effectiveness and potential side effects. Referring the patient to a nutritionist for dietary modifications (Option D) is important for overall health but may not directly address the immediate comfort and quality of life concerns related to fatigue and limited mobility. Helping the patient prioritize energy conservation will allow them to use their limited energy for essential activities, leading to a more comfortable and fulfilling experience while receiving palliative care for end-stage heart failure.

Correct Answer: D

Rationale: The main goal of ethical practice in the nursing profession, including in the community setting, is centered on the welfare of clients and protecting their rights. Nurses have a professional and ethical obligation to prioritize the well-being and best interests of their patients. This includes providing high-quality care, advocating for their patients, supporting their autonomy, and upholding their rights. Ethical nursing practice is not focused on protecting the nurse or co-workers, preventing reprimand from physicians, or solely meeting the satisfaction of patients' families. Ensuring the welfare and rights of clients is the fundamental ethical principle that guides nursing practice.