Adult Health Nursing Study Guide Answers

Correct Answer: B

Rationale: The most appropriate action for the nurse to take when noticing that the patient seems anxious and is avoiding eye contact is to ask the patient if they are feeling anxious and if they would like to talk about it. This approach shows empathy, concern, and openness to addressing the patient's emotional state. By directly acknowledging the patient's behavior and giving them the opportunity to express their feelings, the nurse can create a supportive and caring environment that promotes effective communication and trust between the patient and healthcare provider. It is important to consider the patient's emotional well-being alongside their physical health during consultations.

Correct Answer: A

Rationale: Total knee arthroplasty (TKA), also known as total knee replacement, is a surgical procedure commonly performed to alleviate symptoms and improve function in patients with advanced osteoarthritis of the knee that has not responded to conservative management. During TKA, the damaged cartilage and bone in the knee joint are removed and replaced with prosthetic components. This procedure aims to reduce pain, restore function, and improve the quality of life for individuals with severe osteoarthritis of the knee. High tibial osteotomy (HTO) is typically performed in younger patients with unicompartmental osteoarthritis, while knee arthroscopy and meniscectomy are more targeted towards specific knee conditions and may not provide significant relief in cases of advanced osteoarthritis.

Correct Answer: A

Rationale: The patient is most likely experiencing autonomic dysreflexia. Autonomic dysreflexia is a potentially life-threatening condition that can occur in individuals with spinal cord injuries at the level of T6 or above. It is characterized by a sudden onset of severe hypertension, bradycardia, diaphoresis, flushing, and headache in response to a noxious stimulus below the level of injury. The sudden change in position from supine to sitting likely triggered autonomic dysreflexia in this patient.

Correct Answer: B

Rationale: The most appropriate nursing intervention to facilitate fetal rotation in a woman experiencing persistent occiput posterior position is to assist the mother into a hands-and-knees position. This position can help encourage the baby to rotate into the optimal occiput anterior position for delivery. By being on her hands and knees, gravity can assist in aiding the rotation of the baby. This position can also help relieve pressure on the mother's back and potentially reduce discomfort during labor. Additionally, hands-and-knees position can help open up the pelvis and create more space for the baby to turn. It is a non-invasive and generally well-tolerated intervention to promote fetal rotation in labor.

Correct Answer: C

Rationale: Battery occurs when there is an intentional harmful or offensive contact with a person without their consent. In this scenario, Nurse Edna applied a body restraint to the patient without the doctor's order, which constitutes unauthorized physical contact. The patient did not give consent for the restraint, and Nurse Edna's action could be considered battery. It is important for healthcare providers to obtain proper authorization before using any form of physical restraint on a patient to avoid legal implications such as battery.