Adult Health Nursing Answer Key

Correct Answer: A

Rationale: The patient's presentation of gradual-onset memory loss, confusion, difficulty with complex tasks, disorientation, and functional decline are all classic features of Alzheimer's disease. Alzheimer's disease is a progressive neurodegenerative disorder characterized by the accumulation of abnormal protein deposits in the brain, leading to widespread neuronal damage and cognitive decline. As the disease progresses, patients typically experience worsening memory loss, cognitive impairment, and deficits in activities of daily living, ultimately requiring full-time care and assistance. Other neurodegenerative diseases such as Parkinson's disease, Huntington's disease, and frontotemporal dementia may present with cognitive impairment and behavioral changes, but the specific constellation of symptoms described in the case is most indicative of Alzheimer's disease.

Correct Answer: D

Rationale: The context of a verbal communication is the environment or situation in which the communication takes place. It includes factors such as the physical setting, the social or cultural background, the relationship between the speaker and the listener, and any other relevant conditions that may impact the understanding of the message. Understanding the context is essential for effective communication as it helps to interpret the meaning behind the words spoken and ensures that the message is appropriately received.

Correct Answer: A

Rationale: The patient's presentation with a blood sugar level of 800mg/dL, absence of ketones in the urine, dehydration, and altered mental status points towards Hyperosmolar nonketotic coma (HNKC). HNKC typically occurs in patients with Type 2 diabetes and is characterized by extremely high blood glucose levels (hyperglycemia) without significant ketosis. The absence of ketones in the urine distinguishes HNKC from Diabetic ketoacidosis (DKA). Patients with HNKC often present with severe dehydration, altered mental status, and hyperosmolarity. It is crucial to address the underlying cause of the hyperglycemia, correct dehydration, and normalize blood glucose levels promptly in the management of HNKC.

Correct Answer: A

Rationale: Option A is the most appropriate nursing intervention to facilitate effective communication with the 80-year-old male patient. This approach involves waiting for the patient to be fully awake before discussing important information about the surgery and potential post-surgery events with both the patient and family. This allows the patient to fully comprehend the information provided and ask any necessary questions. Effective communication is crucial in promoting patient understanding and cooperation, especially in older adults who may require additional time to process information due to factors such as age-related cognitive changes. It is important to ensure that the patient receives clear and accurate information to support their recovery process and reduce anxiety.

Correct Answer: A

Rationale: Reed-Sternberg cells are large, abnormal lymphocytes that are characteristic of Hodgkin's Lymphoma. They are typically found in the affected lymph nodes of individuals with Hodgkin's Lymphoma when examined under a microscope. Identifying Reed-Sternberg cells in a lymph node biopsy is a key diagnostic feature of Hodgkin's Lymphoma. This distinguishes Hodgkin's Lymphoma from other types of lymphomas that do not have Reed-Sternberg cells.