Adult Health Nursing Answer Key

Correct Answer: B

Rationale: The patient's symptoms of unilateral nasal congestion, facial pain, and purulent nasal discharge with tenderness over the affected sinus are suggestive of acute sinusitis. Acute sinusitis is typically caused by a viral or bacterial infection leading to inflammation and swelling of the sinus mucosa, resulting in the characteristic symptoms described. The tenderness over the affected sinus indicates inflammation in that area. Allergic rhinitis typically presents with bilateral nasal congestion, clear nasal discharge, and itching, rather than facial pain and purulent discharge. Nasal polyps are associated with chronic conditions and usually lead to more gradual onset of symptoms. A deviated nasal septum may contribute to chronic sinus issues but typically does not present with acute symptoms of infection like purulent discharge and facial pain.

Correct Answer: C

Rationale: The most appropriate nursing action in this situation is to notify the healthcare provider immediately. The symptoms the postpartum client is experiencing - persistent, severe abdominal pain, distention, and absent bowel sounds - are concerning and could indicate a serious underlying issue such as bowel obstruction or other complications. Prompt communication with the healthcare provider is crucial to ensure the client receives the necessary assessment, intervention, and treatment. Encouraging ambulation, providing a heating pad, or administering a laxative are not appropriate actions in this case without first consulting with the healthcare provider due to the severity and potential complexity of the client's symptoms.

Correct Answer: A

Rationale: Confidentiality is the ethical principle that requires healthcare providers to keep client information private and not disclose it without the client's consent. When client information is shared beyond the interdisciplinary team without the client's consent, it breaches the trust and privacy expected in the nurse-client relationship. This breach not only violates the ethical principle of confidentiality but also undermines the client's autonomy and right to control their own personal information. Maintaining confidentiality is crucial for building trust and ensuring the well-being of the client.

Correct Answer: C

Rationale: In situations where a patient's family member is expressing anxiety about their loved one's condition, it is important for the nurse to provide clear and accurate information about the patient's status. By explaining the nature of the injury and reassuring the wife that her husband's condition is stable, the nurse can help alleviate her anxiety and address her concerns in a meaningful way. This intervention focuses on open communication and providing emotional support, which are crucial in helping the family member cope with the situation. It is essential to establish trust and create a supportive environment for the family member during this stressful time.

Correct Answer: C

Rationale: The most effective plan would be for the nurse to educate the entire family at the same time about the disease and medications to treat it (Option C). This approach ensures that each family member receives the same information and understanding about obsessive compulsive disorder (OCD) and its treatment. By educating the entire family simultaneously, it creates a supportive environment where everyone is on the same page and can provide understanding and assistance to the individual with OCD, in this case, Mrs. Juan. It also allows for open communication and collaboration within the family unit, leading to better management and support for Mrs. Juan in dealing with her illness.