Adult Health Nursing Answer Key

Correct Answer: B

Rationale: Monitoring oxygen saturation with pulse oximetry is essential for preventing respiratory depression in a patient prescribed an opioid analgesic. Opioid analgesics can suppress the respiratory drive, leading to respiratory depression. By constantly monitoring the patient's oxygen saturation levels with pulse oximetry, nurses can promptly detect any signs of respiratory depression and intervene early to prevent serious complications. This allows for timely adjustments in the medication dosage or administration of other supportive measures to maintain adequate oxygenation and prevent respiratory compromise. Administering naloxone prophylactically may be necessary in case of an opioid overdose but is not typically done as a preventive measure. Encouraging deep breathing exercises can help prevent respiratory complications postoperatively but may not be sufficient in the presence of opioid-induced respiratory depression. Administering bronchodilators as needed is not directly related to preventing respiratory depression caused by opioid analgesics.

Correct Answer: C

Rationale: Meningomyelocele is a type of neural tube defect where there is a protrusion of the spinal cord, cerebrospinal fluid, and meninges through a defect in the vertebrae, forming a sac on the surface of the back. This condition occurs during fetal development when the neural tube fails to close completely, leading to the exposure of the spinal cord and its coverings. This herniation can result in a range of neurological deficits and complications, requiring surgical repair shortly after birth to prevent further damage and infections.

Correct Answer: B

Rationale: After being infected with the human immunodeficiency virus (HIV), it can take an average of 8-10 years before the development of Acquired Immunodeficiency Syndrome (AIDS) if left untreated. However, AIDS can manifest sooner in some cases, typically within 2 years, especially if the person's immune system is already significantly compromised or if they have other underlying health conditions. Thus, the manifestation of AIDS can vary, but it generally occurs within a range of 2 to 10 years after initial HIV infection.

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: When a woman in active labor experiences persistent fetal malposition, such as a transverse lie presentation, assisting the mother into a hands-and-knees position is a nursing intervention to prioritize. This position can help encourage the fetus to rotate into a more favorable position for delivery, such as a head-down position. By placing the mother in a hands-and-knees position, gravity can assist in shifting the fetus to the correct position. This intervention is non-invasive and can be effective in promoting the progress of labor and avoiding the need for more invasive interventions like instrumental delivery or cesarean section. However, if the fetus does not rotate or if there are signs of fetal distress, further interventions may be necessary.