Adult Health Nursing Quizlet Final

Correct Answer: C

Rationale: The most appropriate nursing action for managing a patient with dependent edema in the lower extremities is to administer diuretics as prescribed. Diuretics help the body remove excess fluid, reducing swelling and edema in the extremities. It is important to follow the healthcare provider's orders for administering diuretics to ensure the patient's fluid balance is managed effectively. While elevating the legs above heart level and applying compression stockings may provide temporary relief, addressing the underlying cause of fluid retention with diuretics is essential for long-term management of the edema in a patient with heart failure. Encouraging increased fluid intake would not be appropriate in this case, as the focus should be on reducing fluid overload rather than increasing fluid intake.

Correct Answer: D

Rationale: Restlessness caused by pain often manifests as increased perspiration and constant change of position. When a person is in pain, they may become sweaty or clammy due to increased sympathetic nervous system activity. Additionally, they may constantly shift or fidget in an attempt to find a more comfortable position that can alleviate the pain they are experiencing. Therefore, it is crucial for Nurse Chona to accurately document these behaviors as signs of pain-related restlessness. Difficulty of breathing (Option A), increased respiratory rate and blood pressure (Option B), and increased heart rate (Option C) are more indicative of hypoxia or respiratory distress rather than pain-related restlessness.

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: D

Rationale: The clinical presentation of a patient with chronic kidney disease (CKD) presenting with weakness, anorexia, confusion, severe anemia, low reticulocyte count, elevated serum creatinine, and decreased erythropoietin levels is most consistent with renal failure-associated anemia. In CKD, the kidneys are unable to produce adequate amounts of erythropoietin, a hormone responsible for stimulating red blood cell production in the bone marrow. The decreased erythropoietin levels lead to a state of anemia, characterized by low hemoglobin levels and subsequent symptoms of fatigue and weakness. The anemia in renal failure is typically normocytic and normochromic. Additionally, the elevated serum creatinine in this patient is a hallmark of kidney dysfunction.

Correct Answer: A

Rationale: Administering a stool softener as ordered is the most appropriate nursing intervention for a postpartum client experiencing severe perineal pain and difficulty passing stools following a vaginal delivery. Stool softeners help to soften the stool, making it easier for the client to pass without straining, which can exacerbate perineal pain. It is important to follow the healthcare provider's orders when administering medications to ensure proper dosing and effectiveness. Encouraging the client to refrain from defecation may lead to constipation and worsen the situation. Applying ice packs to the perineum can provide temporary pain relief, but addressing the underlying issue of constipation with a stool softener is more effective in the long term. Providing education on proper perineal hygiene is important for overall postpartum care, but addressing the immediate issue of constipation with a stool softener takes precedence in this scenario.