Adult Health Nursing Answer Key

Correct Answer: A

Rationale: The clinical presentation of severe lower abdominal pain and vaginal bleeding in a pregnant woman, along with cervical motion tenderness, unilateral adnexal tenderness, and an adnexal mass on the affected side, is highly concerning for an ectopic pregnancy. Ectopic pregnancy occurs when a fertilized egg implants outside the uterus, most commonly in the fallopian tube. The presence of an adnexal mass and tenderness on one side is indicative of potential tubal involvement and can mimic symptoms of pelvic inflammatory disease. Prompt evaluation and management are crucial in ectopic pregnancy to prevent life-threatening complications associated with rupture of the fallopian tube.

Correct Answer: D

Rationale: During the first contact with a patient, a nurse should demonstrate caring, encouraging, and comforting behaviors. These qualities help create a positive and supportive environment for the patient. However, compelling behavior, which implies forcing or pressuring someone to do something, is not appropriate during the initial interaction with a patient. It is essential for the nurse to build trust and rapport with the patient, and compelling behavior can be counterproductive to establishing a nurturing relationship. Thus, compelling is the exception among the given choices for the nurse's behavior during the first contact with a patient.

Correct Answer: D

Rationale: A nurse should have a sense of accountability for his actions. This means taking responsibility for one's decisions and behaviors while working in the healthcare setting. Accountability ensures that the nurse is aware of the consequences of his actions and is willing to accept ownership and follow through on commitments. It is a critical aspect of nursing practice as it helps maintain professional standards, promote patient safety, and uphold trust and integrity within the profession. Nurses are entrusted with the well-being of their patients, so being accountable for their actions is essential in providing high-quality care and maintaining ethical standards.

Correct Answer: B

Rationale: The nurse's best approach to address the patient's fear of needles before a blood draw is to provide the patient with information about relaxation techniques and distraction methods (Option B). Dismissing the patient's fear (Option A), ignoring the fear and proceeding quickly (Option C), or telling the patient that the fear is irrational and unfounded (Option D) would not be helpful and could potentially escalate the patient's anxiety. Providing information on relaxation techniques such as deep breathing or visualization, as well as distraction methods like listening to music or engaging in conversation, can help the patient feel more comfortable and reduce their fear and anxiety during the blood draw procedure. It is important for the nurse to acknowledge and address the patient's concerns in a supportive and empathetic manner to build trust and ensure a successful blood draw experience.

Correct Answer: B

Rationale: Refeeding syndrome is a potentially dangerous condition that can occur in malnourished individuals when nutrition is reintroduced too quickly. It is characterized by shifts in electrolytes, fluid imbalance, and metabolic abnormalities. Monitoring for decreased bowel sounds, nausea, bloating, and abdominal distention is the priority action to prevent complications associated with refeeding syndrome. These symptoms can indicate gastrointestinal issues such as ileus or overfeeding, which can lead to further complications. Early recognition and intervention can help prevent serious consequences of refeeding syndrome.