Adult Health Nursing Answer Key

Correct Answer: B

Rationale: Urticaria (hives) and pruritus (itching) are common signs of an allergic reaction to antibiotics, including those used for GBS prophylaxis during labor. Other signs of an adverse reaction may include flushing, fever, chills, and anaphylaxis. It is important to monitor the woman closely for any signs of an allergic reaction and to intervene promptly if one occurs to ensure the safety of both the mother and the baby.

Correct Answer: B

Rationale: Convenience sampling involves selecting participants who are readily available or easy to access. In this scenario, choosing to interview nurses who happen to be in the conference room where the activity is scheduled falls under convenience sampling as they are easily accessible at that moment. While convenience sampling may be convenient, it may introduce bias and may not represent the entire population accurately.

Correct Answer: C

Rationale: The patient is presenting with sudden-onset weakness and sensory loss on one side of the body along with difficulty speaking and understanding speech, which are classic symptoms of a stroke. The involvement of the right middle cerebral artery territory on imaging suggests an acute infarction, confirming an ischemic stroke. Ischemic stroke occurs due to a blockage or obstruction within a blood vessel supplying blood to the brain, leading to a lack of oxygen and nutrients reaching brain tissue. This results in neurological deficits corresponding to the affected area of the brain. In contrast, a transient ischemic attack (TIA) would present with similar symptoms but resolve within 24 hours without evidence of acute infarction on imaging. Intracerebral hemorrhage and subarachnoid hemorrhage involve bleeding into the brain tissue or the space surrounding the brain, respectively, resulting in different clinical presentations.

Correct Answer: A

Rationale: Confidentiality is the ethical principle that requires healthcare providers to keep client information private and not disclose it without the client's consent. When client information is shared beyond the interdisciplinary team without the client's consent, it breaches the trust and privacy expected in the nurse-client relationship. This breach not only violates the ethical principle of confidentiality but also undermines the client's autonomy and right to control their own personal information. Maintaining confidentiality is crucial for building trust and ensuring the well-being of the client.

Correct Answer: A

Rationale: The nurse should encourage the parents to relate to each twin individually to enhance the attachment process. Building a strong attachment between the parents and each twin individually is vital for their emotional and psychological development. By spending quality one-on-one time with each twin, the parents can foster a unique bond with them, which can positively impact their relationship and overall development. This approach also helps prevent favoritism and ensures that each twin receives the attention and care they need to thrive.