Adult Health Nursing Quizlet Final

Correct Answer: A

Rationale: The most appropriate intervention for managing hepatic encephalopathy in this patient receiving palliative care for end-stage liver disease is to administer lactulose or other ammonia-lowering agents to reduce ammonia levels. Hepatic encephalopathy is believed to be primarily caused by the accumulation of ammonia in the bloodstream due to compromised liver function. Lactulose works by acidifying the gut lumen, which facilitates the excretion of ammonia in the form of ammonium ions. By reducing ammonia levels, hepatic encephalopathy symptoms, such as confusion and altered mental status, can be improved. Initiating other supportive measures like managing precipitating factors, maintaining hydration, and addressing nutritional issues should also be part of the holistic approach in managing hepatic encephalopathy in palliative care. However, addressing the underlying cause by reducing ammonia levels with lactulose is the priority intervention in this scenario.

Correct Answer: C

Rationale: The description provided is classical for fungal keratitis. Fungal keratitis typically presents with a yellowish-white spot on the cornea, often surrounded by a ring of inflammation. Branching, filamentous opacities extending from the corneal lesion are commonly seen on slit-lamp examination in cases of fungal keratitis. This condition is often associated with risk factors such as trauma with organic material or contact lens wear. Prompt diagnosis and treatment with antifungal agents are crucial in managing fungal keratitis to prevent potential complications.

Correct Answer: C

Rationale: Maintaining patient confidentiality is a foundational principle in healthcare ethics. Nurses are obligated to keep all information about patients confidential, which means not disclosing any patient-related information to unauthorized individuals. This includes refraining from discussing patient cases with others who are not directly involved in the care of the patient. Sharing patient information without consent can be a breach of trust and privacy, which can have legal and ethical implications. Therefore, in order to uphold the principle of confidentiality, nurses must keep all matters about the patient as a secret.

Correct Answer: C

Rationale: In a postpartum client exhibiting signs of anxiety, restlessness, and palpitations, it is essential to prioritize notifying the healthcare provider immediately. These symptoms could indicate a serious condition such as postpartum preeclampsia, postpartum hemorrhage, or postpartum cardiomyopathy, which require urgent medical attention. It is crucial to rule out any life-threatening conditions and ensure the client receives appropriate treatment promptly. While relaxation techniques and deep breathing exercises can be helpful for anxiety management in some cases, in this situation, the priority is to ensure the client's safety and well-being by seeking medical evaluation and intervention. Administering a benzodiazepine without consulting the healthcare provider first could potentially mask symptoms or interact with other medications the client may be taking, making it unsafe to proceed without professional guidance.

Correct Answer: A

Rationale: The nurse's priority action when noticing a spill of bodily fluids on the floor while preparing the operating room for a surgical procedure is to clean up the spill using appropriate infection control measures. This is essential to prevent the spread of infections and ensure a safe surgical environment for both patients and healthcare providers. Cleaning up the spill promptly and properly reduces the risk of contamination and subsequent infections. Once the spill is cleaned up, the nurse can then proceed with documenting the spill, placing warning signs to alert others, and continuing with the preparation of the OR as planned. But the initial priority is to eliminate the immediate threat posed by the spill through proper cleaning and infection control measures.