Adult Health Nursing Study Guide Answers

Correct Answer: A

Rationale: The patient is most likely experiencing autonomic dysreflexia. Autonomic dysreflexia is a potentially life-threatening condition that can occur in individuals with spinal cord injuries at the level of T6 or above. It is characterized by a sudden onset of severe hypertension, bradycardia, diaphoresis, flushing, and headache in response to a noxious stimulus below the level of injury. The sudden change in position from supine to sitting likely triggered autonomic dysreflexia in this patient.

Correct Answer: A

Rationale: The FIRST action of the nurse should be to reassess the client experiencing dyspnea despite continuous oxygen therapy. Reassessment would involve checking the client's respiratory status, oxygen saturation levels, vital signs, and overall condition to gather more information about the situation. This will help the nurse identify any potential causes of the dyspnea and determine the appropriate next steps for intervention. Assessing the client before proceeding with any other actions is crucial in providing safe and effective care.

Correct Answer: C

Rationale: Delegation by succession is the act of assigning a specific task or responsibility to someone temporarily while the usual person in charge is absent or unavailable. In this scenario, the unit manager is delegating her responsibilities to her assistant unit manager while she is on leave, indicating a temporary transfer of duties. This allows for a smooth continuity of operations within the unit during the manager's absence.

Correct Answer: B

Rationale: The best approach for the nurse in this situation is to listen actively to the patient's religious beliefs, respect their autonomy, and explore alternative treatment options. It is important for the nurse to understand and acknowledge the patient's perspective, even if it conflicts with the recommended treatment plan. By showing respect for the patient's beliefs and involving them in the decision-making process, the nurse can work collaboratively with the patient to find a solution that aligns with their religious beliefs while also addressing their medical needs. This approach promotes patient-centered care and helps build a trusting and therapeutic relationship between the nurse and the patient.

Correct Answer: C

Rationale: In a missed abortion, the embryo has died, but the products of conception remain in the uterus, leading to the visualization of a gestational sac without an embryo on ultrasound. This is a type of missed miscarriage where the woman may not have any symptoms initially and the diagnosis is made during a routine ultrasound. The most common presenting symptom is painless vaginal bleeding. The absence of an embryo within the gestational sac can be confirmed through serial ultrasound examinations showing no fetal growth or cardiac activity. It is important for healthcare providers to provide appropriate counseling and management options to support the patient through this emotional experience.