Adult Health Nursing Answer Key

Correct Answer: B

Rationale: The healthcare team should prioritize implementing environmental modifications to promote orientation in a patient with delirium. Delirium is a state of acute confusion and agitation that can be triggered by various factors such as medications, infections, or metabolic disturbances. Environmental modifications involve creating a calm, quiet, and well-lit environment for the patient. Promoting proper orientation through the use of clocks, calendars, and familiar objects can help reduce confusion and improve the patient's understanding of their surroundings. These interventions are non-pharmacological and aim to address the underlying causes of delirium while minimizing the need for additional medications that may have potential side effects. Antipsychotic medications and benzodiazepines should be used judiciously and under close supervision due to the risk of adverse effects in older adults and critically ill patients. Referring the patient to a psychiatrist may be considered if the delirium is complex or if there are underlying psychiatric issues contributing to the presentation.

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.

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: B

Rationale: The nurse's best approach to address the patient's fear of needles before a blood draw is to provide the patient with information about relaxation techniques and distraction methods (Option B). Dismissing the patient's fear (Option A), ignoring the fear and proceeding quickly (Option C), or telling the patient that the fear is irrational and unfounded (Option D) would not be helpful and could potentially escalate the patient's anxiety. Providing information on relaxation techniques such as deep breathing or visualization, as well as distraction methods like listening to music or engaging in conversation, can help the patient feel more comfortable and reduce their fear and anxiety during the blood draw procedure. It is important for the nurse to acknowledge and address the patient's concerns in a supportive and empathetic manner to build trust and ensure a successful blood draw experience.

Correct Answer: C

Rationale: During a transurethral resection of the prostate (TURP), fluid irrigation is commonly used to distend the bladder and flush out tissue debris. However, it is important to prioritize preventing fluid overload in the patient. Limiting the duration of irrigation fluid instillation is a crucial action to prevent excessive fluid absorption and subsequent fluid overload. Prolonged irrigation may lead to an increased risk of fluid overload and electrolyte imbalances, which can result in serious complications such as hyponatremia and fluid volume excess. Monitoring the patient's serum electrolyte levels can be important, but limiting the duration of irrigation is a more immediate and proactive measure to prevent fluid overload. Administering diuretic medications before the procedure may not be appropriate without assessing the patient's specific fluid status and needs. Adjusting the irrigation fluid temperature, while important for hemostasis, does not directly