Adult Health Nursing Study Guide Answers

Correct Answer: B

Rationale: Uterine hyperstimulation, also known as tachysystole, is a condition characterized by frequent and intense uterine contractions with minimal rest intervals. This can lead to maternal fatigue and decreased fetal oxygenation due to the insufficient time for the uterus to relax and refill with oxygenated blood between contractions. Uterine hyperstimulation can be caused by various factors such as excessive use of uterotonics (oxytocin or prostaglandins), improper labor induction techniques, or maternal conditions like previous uterine surgery. It is essential for the nurse to assess for signs of uterine hyperstimulation and take appropriate interventions to prevent potential complications for both the mother and the baby.

Correct Answer: C

Rationale: It is crucial to ensure that the autoclave is functioning properly to achieve proper sterilization of surgical instruments. If the autoclave is not reaching the required temperature, it signifies a technical issue that needs to be addressed promptly. The nurse should notify the sterile processing department immediately and request maintenance to investigate and resolve the problem. Continuing with sterilization without addressing the temperature issue can compromise the effectiveness of sterilization and pose a risk of infection to patients. Adjusting the settings on the autoclave or using an alternative method of sterilization are not appropriate actions in this situation.

Correct Answer: C

Rationale: An amniotic fluid embolism is a rare and life-threatening complication during labor and delivery. It occurs when amniotic fluid or fetal cells enter the maternal circulation, triggering a rapid immune response that can lead to cardiovascular collapse and respiratory failure. The priority nursing intervention for a woman in active labor diagnosed with an amniotic fluid embolism is to initiate cardiopulmonary resuscitation (CPR) to support her vital functions and circulation. Providing immediate CPR can help sustain her until further medical interventions can be implemented. Administering oxygen and preparing for a cesarean section may be necessary but should occur after CPR is initiated to stabilize the woman's condition. Inserting an indwelling urinary catheter is not the priority in this emergency situation, as maintaining adequate cardiac and respiratory function takes precedence.

Correct Answer: A

Rationale: The patient's presentation of recurrent episodes of postnasal drip, chronic cough, halitosis, and foul-smelling, yellowish discharge from the middle meatus is highly suggestive of chronic rhinosinusitis. The presence of nasal polyps further supports this diagnosis. Chronic rhinosinusitis with nasal polyps is characterized by inflammation of the paranasal sinuses, leading to symptoms such as nasal congestion, postnasal drip, cough, and a reduced sense of smell. The yellowish discharge and foul odor are typical findings in cases of chronic rhinosinusitis with secondary bacterial infection. Nasal endoscopy may reveal edematous nasal mucosa and polyps obstructing the middle meatus, contributing to the symptoms described by the patient. Management typically involves a combination of medical therapies such as intranasal corticosteroids, saline irrigation, and antibiotics, and in some cases, surgical intervention

Correct Answer: B

Rationale: The nurse's best response when a patient asks about alternative treatment options is to provide the patient with information about those options, including their benefits and risks. It is important for the nurse to support the patient in their exploration of different treatment approaches and empower them to make informed decisions about their care. Dismissing the question, ignoring it, or discouraging alternative treatments are not appropriate responses and may hinder the patient's ability to make choices that align with their values and preferences. Therefore, providing information and facilitating an open discussion about alternative treatments is the most appropriate approach for the patient's best interest.