Adult Health Nursing Study Guide Answers

Correct Answer: A

Rationale: The appropriate nursing intervention in this case is to encourage the mother to walk to facilitate labor progression. The patient is in early labor with contractions every 5 minutes, lasting 45 seconds each, and her cervix is dilated to 3 cm. Encouraging the mother to walk can help gravity assist the descent of the baby and promote cervical dilation. Walking can also help alleviate some discomfort and encourage labor progression. It is important to promote natural, non-invasive methods to support the progress of labor before considering medical interventions such as oxytocin or cesarean section. Relaxation techniques can also be beneficial in managing pain during labor.

Correct Answer: A

Rationale: Bulimia nervosa is an eating disorder characterized by binge eating followed by compensatory behaviors such as self-induced vomiting, fasting, or excessive exercise. The repeated purging in bulimia can lead to electrolyte imbalances, such as hypokalemia (low potassium levels). Hypokalemia is a serious condition that can affect the function of the heart's electrical system, potentially leading to the development of cardiac arrhythmias (irregular heartbeats) and even cardiac arrest, which can result in death. Therefore, in a bulimic patient like Sherry, the risk of death is most likely due to the combination of hypokalemia and its complications, such as cardiac arrhythmias and arrest.

Correct Answer: A

Rationale: The best thing to do next is to turn off the fan immediately. The fact that the electric fan is stopping every now and then and sparking at intervals indicates a potential electrical issue or malfunction. This situation poses a safety hazard as it increases the risk of an electrical fire or damage to the fan. Turning off the fan immediately will help prevent any further damage or potential danger. After turning off the fan, it would be advisable to call for maintenance to inspect and repair the fan to ensure it is safe to use again.

Correct Answer: A

Rationale: The symptoms described - sudden-onset severe headache, nausea, vomiting, photophobia, neck stiffness, and positive Kernig and Brudzinski signs - are classic manifestations of meningitis. Meningitis is an inflammation of the meninges, the protective membranes covering the brain and spinal cord, often caused by infection. The sudden onset of these symptoms and signs, along with neck stiffness and positive Kernig and Brudzinski signs (indicative of meningeal irritation), strongly suggest meningitis as the most likely diagnosis in this scenario.

Correct Answer: A

Rationale: The clinical presentation of recurrent fever, sore throat, cervical lymphadenopathy, leukocytosis with atypical lymphocytes, and positive heterophile antibody test (Monospot test) is highly indicative of infectious mononucleosis caused by the Epstein-Barr virus (EBV). EBV is a member of the herpesvirus family and is a common cause of infectious mononucleosis. The atypical lymphocytes seen on peripheral blood smear are reactive T lymphocytes responding to the EBV infection. The Monospot test detects heterophile antibodies produced in response to EBV infection.