Adult Health Nursing Answer Key

Correct Answer: B

Rationale: The most appropriate response from the nurse when a patient expresses frustration with the treatment plan proposed by the healthcare team is to empathize with the patient's frustration and explore their concerns further. It is important to actively listen to the patient, acknowledge their feelings, and address any questions or uncertainties they may have about the treatment plan. By engaging in open communication and demonstrating empathy, the nurse can foster a therapeutic relationship with the patient and work towards finding a solution that is mutually agreeable and beneficial for the patient's well-being. Dismissing the patient's concerns (Option A) or ignoring their frustration (Option C) can lead to a breakdown in communication and trust, which may ultimately impact the patient's compliance with the treatment plan. Similarly, telling the patient that they have no choice but to follow the treatment plan (Option D) can be perceived as dismissive and confrontational, which is not conducive to promoting patient-centered care.

Correct Answer: D

Rationale: The priority nursing initiative for Nurse May should be to set up a mental health program in the community. This proactive approach focuses on prevention, early intervention, and support for individuals experiencing mental health issues. By setting up a mental health program, Nurse May can address the root causes of mental problems in young adults in the community, provide education and awareness, offer counseling services, and promote mental well-being. This initiative can have a long-term impact on the mental health of individuals and help reduce the incidence of mental problems in the community. Setting up a mental health program is a holistic and sustainable approach to addressing mental health issues in the community.

Correct Answer: B

Rationale: Spironolactone is a potassium-sparing diuretic commonly used in the management of heart failure. One of the significant side effects of spironolactone is hyperkalemia, which is an elevated level of potassium in the bloodstream. Spironolactone works by blocking the action of aldosterone, a hormone that regulates potassium and sodium balance in the body. By inhibiting aldosterone, spironolactone reduces potassium excretion in the urine, leading to potential accumulation of potassium in the body.

Correct Answer: B

Rationale: In a patient with acute respiratory failure and hypercapnia due to a COPD exacerbation, the most appropriate intervention is the initiation of non-invasive positive pressure ventilation (NIPPV). NIPPV helps improve ventilation and oxygenation by providing mechanical support to the patient's breathing without the need for endotracheal intubation. It can reduce the work of breathing, decrease carbon dioxide retention, and improve respiratory muscle function. This intervention is particularly beneficial for COPD exacerbations as it can help alleviate hypercapnia and hypoxemia, leading to improved outcomes and potentially reducing the need for invasive ventilation methods. Therefore, NIPPV is the recommended management strategy in this scenario.

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