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: I. It blocks the urethra: Benign Prostatic Hyperplasia (BPH) is a condition in which the prostate gland enlarges and can squeeze the urethra, leading to urinary symptoms such as difficulty urinating. This statement correctly explains one of the effects of BPH on the urinary system.

Correct Answer: A

Rationale: By randomly selecting individuals in the community for the project, Nurse Mary is upholding the ethical principle of autonomy. Autonomy refers to respecting individuals' right to make their own decisions and choices. In this scenario, Nurse Mary is not imposing her own preferences or biases but rather allowing individuals in the community to have an equal opportunity to participate in the project. Random selection ensures that the process is fair and gives everyone an equal chance to be involved, respecting their autonomy.

Correct Answer: A

Rationale: Natural killer (NK) cells play a vital role in the innate immune response by identifying and eliminating virus-infected cells, as well as tumor cells, without the need for prior exposure or activation. NK cells are able to detect abnormal cells by recognizing changes in the cell surface molecules, such as downregulation of MHC class I molecules. Once activated, NK cells release cytotoxic granules containing perforin and granzyme, leading to the destruction of the target cell. This direct killing mechanism is crucial for controlling viral infections and preventing the development of tumors. NK cells do not produce antibodies (option B), present antigens to T cells (option C), or release cytokines to recruit other immune cells (option D) as their primary function in the immune response.

Correct Answer: D

Rationale: COPD (Chronic Obstructive Pulmonary Disease) patients often struggle with breathing difficulties due to their conditions, hence it is important for them to conserve their energy as much as possible. Standing while performing activities like shaving or combing hair can be physically demanding for COPD patients as it requires more energy and can lead to increased shortness of breath. It is recommended for COPD patients to sit down or assume a supported position (like the tripod position with elbows supported on a table) to reduce the energy expended and minimize the strain on their respiratory system. Standing in front of the mirror while performing grooming activities is a task that can be easily modified to a seated position, thus conserving energy and reducing the risk of exacerbating breathing difficulties for COPD patients.