Adult Health Nursing First Chapter Quizlet

Correct Answer: D

Rationale: Ella's feeling of joining Lory in heaven is best categorized as suicidal ideation. Suicidal ideation refers to thoughts or fantasies about dying, including thoughts of one's own death or thoughts of wanting to harm oneself. In this scenario, Ella is not explicitly expressing any immediate intent to harm herself or others, nor is she exhibiting paranoia or making a direct threat. Instead, her mention of joining Lory in heaven suggests that she is contemplating the idea of death, which falls under the category of suicidal ideation. It is essential to take such thoughts seriously and seek appropriate help and support for the individual experiencing them.

Correct Answer: A

Rationale: A nurse should wear sterile gloves and a surgical mask during a lumbar puncture procedure to maintain procedural asepsis. Sterile gloves help prevent contamination of the procedure site and reduce the risk of introducing microorganisms to the puncture site. Surgical masks help minimize the risk of respiratory secretions contaminating the sterile field, which is essential for maintaining asepsis during the procedure. Additionally, proper hand hygiene before and after the procedure is crucial in preventing the spread of infection.

Correct Answer: A

Rationale: The most important intervention for managing ventilator-associated pneumonia (VAP) caused by methicillin-resistant Staphylococcus aureus (MRSA) in a patient undergoing mechanical ventilation in the ICU is to start appropriate antimicrobial therapy targeting MRSA. Vancomycin or linezolid are commonly used antibiotics for MRSA infections. These medications are effective against MRSA and can help in treating the infection and preventing further complications. It is crucial to initiate antimicrobial therapy promptly once the diagnosis of VAP caused by MRSA is suspected or confirmed to improve patient outcomes. Other interventions such as bronchoalveolar lavage for diagnostic purposes, contact precautions, or antifungal therapy may be relevant but the priority is to start effective antibiotic therapy to target the specific pathogen causing the infection.

Correct Answer: C

Rationale: The correct next step after positioning the child is to drop the medicine into the ear canal. This is typically the next step in administering ear drops for a child. The cleaning and positioning steps are to prepare the ear for receiving the medication. Dropping the medicine into the ear canal ensures that the medication can reach the affected area effectively. Once the medicine is dropped into the ear canal, it is important to follow any additional instructions provided by the healthcare provider regarding keeping the ear in a certain position or any other post-administration care steps.

Correct Answer: C

Rationale: The nurse should always keep Tensilon (Edrophonium) at the bedside of a client with myasthenia gravis. Tensilon is a fast-acting cholinesterase inhibitor that can be used for the diagnosis and emergency treatment of myasthenia crisis. It helps improve muscle strength temporarily by increasing the levels of acetylcholine at the neuromuscular junction. Administering Tensilon can help differentiate between a myasthenic crisis (marked improvement in muscle strength) and a cholinergic crisis (no improvement or worsening of muscle weakness). Keeping Tensilon at the bedside allows for prompt administration in case of a myasthenic crisis.