Adult Health Med Surg Nursing Test Banks

Correct Answer: A

Rationale: The bioethical issue described in option A revolves around the concept of advance directives. Advance directives are legal documents that outline a person's wishes regarding medical treatment in the event that they are unable to communicate those wishes themselves. In this scenario, the issue pertains to the withholding of food and treatment based on a written advance directive that was made before the patient suffered permanent brain damage. This raises important ethical considerations about respecting a patient's autonomy and adhering to their previously expressed wishes, even in difficult circumstances. The decision to withhold treatment in such a situation is a complex bioethical issue that needs to be handled carefully while balancing the principles of autonomy and beneficence.

Correct Answer: B

Rationale: The correct charting rule to keep the nurse legally safe is to document worries and all concerns as verbalized by the patient (Choice I). This is important for accurately reflecting the patient's condition, communication, and potential interventions. Charting at the end of the shift only (Choice II) is not recommended as it can lead to missed important details or delayed documentation. Discussing recorded cases and diagnoses of the patient (Choice III) breaches patient confidentiality and violates HIPAA laws. Recording all information verbalized by the patient and family (Choice IV) may include unnecessary details and could potentially lead to misinterpretation or misunderstanding, which might not be legally advantageous.

Correct Answer: C

Rationale: The nurse does not need to determine the age of Excel when planning for Sonny's oxygen therapy. This information is irrelevant to the specific care requirements of Sonny's oxygen therapy. Sonny's age, medical history, respiratory status, and oxygen needs are the key considerations in planning for his oxygen therapy. The nurse should focus on factors such as the need for a humidifier, length of tubing, and the manner of administering oxygen (continuous or intermittent) to ensure effective and safe delivery of oxygen therapy to Sonny.

Correct Answer: D

Rationale: Weight reduction is the most important focus in the health teachings provided by the nurse. Maintaining a healthy weight is crucial for overall well-being and can significantly reduce the risk of various health conditions such as heart disease, diabetes, and certain cancers. By emphasizing weight reduction, the nurse can help improve the patient's overall health and quality of life. Jogging a mile a day and vigorous exercise are beneficial for weight management, but it is important to address the root cause of potential health problems which in this case may be excess weight. Moreover, emphasizing the importance of weight reduction does not necessarily mean encouraging extreme dieting; instead, it involves promoting a balanced and healthy approach to eating and physical activity.

Correct Answer: C

Rationale: Tetanus toxoid provides long-lasting active immunity. When a person is vaccinated with tetanus toxoid, their immune system is stimulated to produce antibodies against the tetanus toxin. These antibodies provide protection against tetanus infection by recognizing and neutralizing the toxin if the person is exposed to the bacteria that causes tetanus in the future. This active immune response can last for many years, providing ongoing protection against tetanus. However, booster doses are recommended every 10 years to maintain adequate levels of protection.