Adult Health Nursing Test Bank

Correct Answer: A

Rationale: The correct answer is A because obtaining the client's own consent is the first step in ensuring the client's autonomy and right to make decisions about their own care. This is in line with ethical principles of informed consent. Choices B, C, and D are incorrect because consent should come directly from the client, not from a spouse, family member, or social worker. Choice B violates the principle of individual autonomy, choice C is not the priority before admission, and choice D is not the appropriate person to provide consent.

Correct Answer: A

Rationale: The correct answer is A because a viral illness few weeks before can trigger Guillain-Barre Syndrome (GBS) due to the body's immune response attacking the peripheral nerves. Encephalitis (B), severe bacterial infection (C), and meningitis (D) are not directly linked to GBS pathophysiology. Viral infections are known to precede GBS development, making choice A the most appropriate option.

Correct Answer: A

Rationale: The correct answer is A: Bleeding. Chemotherapy can lead to low platelet counts (thrombocytopenia), increasing the risk of bleeding. The priority goal of the nurse is to prevent bleeding by taking precautions such as avoiding invasive procedures, using soft toothbrushes, and monitoring for signs of bleeding. Infection (B) is important but not the priority as bleeding can be life-threatening. Hypotension (C) is not directly related to thrombocytopenia. Diarrhea (D) is a potential side effect of chemotherapy but is not the priority when considering thrombocytopenia.

Correct Answer: A

Rationale: The correct answer is A: Myasthenia gravis. In myasthenia gravis, there is a decrease in acetylcholine receptors at the neuromuscular junction, leading to muscle weakness and fatigue. This occurs due to autoimmune destruction of these receptors. ALS (B) affects motor neurons, not acetylcholine receptors. Guillain-Barre syndrome (C) is an autoimmune disorder affecting peripheral nerves, not neuromuscular junctions. Muscular dystrophy (D) is a genetic disorder causing muscle degeneration, not affecting acetylcholine receptors.

Correct Answer: A

Rationale: The correct answer is A: Enhances the delivery of quality nursing care. Supervision and delegation are essential in ensuring efficient and effective healthcare delivery. By supervising and delegating tasks appropriately, the head nurse can ensure that staff members are performing their duties competently, which ultimately leads to improved quality of patient care. Supervision helps in monitoring staff performance, providing feedback, and offering guidance when needed. Delegation ensures that tasks are allocated to the right staff members based on their skills and abilities, optimizing the workflow. Choices B, C, and D are incorrect because they do not directly relate to the primary purpose of supervision and delegation, which is to enhance the quality of nursing care through effective oversight and task allocation.