Adult Health Nursing Study Guide Answers

Correct Answer: C

Rationale: In the provided scenario, the patient is scheduled for Lithotripsy under spinal anesthesia. This means that the nurse needs to communicate with the department of anesthesia to coordinate and prepare for the procedure. Anesthesia departments are responsible for administering various types of anesthesia, including spinal anesthesia, to ensure patients are comfortable and pain-free during medical procedures. Therefore, contacting the department of anesthesia is crucial in this situation to ensure that the necessary arrangements are in place for the patient's lithotripsy procedure.

Correct Answer: A

Rationale: Showing positive interpersonal relationships is the best evidence of a family coping well when their family coping index on therapeutic competence is rated as coping well. Positive interpersonal relationships indicate that family members are effectively communicating, supporting each other, and resolving conflicts in a healthy manner. This reflects strong family dynamics, emotional resilience, and adaptability which are important aspects of effective coping. While the other options (B, C, D) are beneficial activities or behaviors, positive interpersonal relationships directly demonstrate the family's ability to cope well together, making it the most relevant evidence for a high therapeutic competence rating.

Correct Answer: B

Rationale: The nurse should monitor the International Normalized Ratio (INR) closely during anticoagulant therapy for the prevention of VTE. The INR measures the clotting ability of the blood and is used to monitor the effectiveness of anticoagulant therapy, such as warfarin. Maintaining the INR within the target therapeutic range is crucial to prevent both excessive bleeding due to over-anticoagulation and clotting events due to under-anticoagulation. Close monitoring of the INR helps healthcare providers adjust the anticoagulant dosage as needed to ensure optimal therapeutic outcomes and minimize risks. Platelet count, serum sodium levels, and blood urea nitrogen (BUN) are important laboratory parameters to monitor for other medical conditions but are not specific to anticoagulant therapy.

Correct Answer: A

Rationale: Physiologic jaundice in newborns is a common and typically benign condition caused by the immaturity of the newborn's liver. The correct statement about physiologic jaundice is that it occurs due to an imbalance between the production and elimination of bilirubin. In contrast, Option A is the false statement because it incorrectly states that physiologic jaundice is caused by impairment in the removal of bilirubin deficiency in the production of glucuronide transferase. This statement is inaccurate as physiologic jaundice results from the immature liver's reduced ability to conjugate bilirubin.

Correct Answer: A

Rationale: The healthcare team should prioritize administering lactulose or other ammonia-lowering agents to manage hepatic encephalopathy in a patient with acute liver failure. Hepatic encephalopathy is a neuropsychiatric syndrome that occurs in patients with liver dysfunction, leading to the accumulation of ammonia and other neurotoxic metabolites in the bloodstream. Lactulose works by acidifying the colon, which promotes the conversion of ammonia to ammonium, a less toxic form that can be excreted in the stool. By reducing the levels of ammonia, lactulose helps improve the neurological symptoms associated with hepatic encephalopathy.