Adult Health Nursing Test Banks

Correct Answer: C

Rationale: The health care team will try the oral route first for Ms. C for delivering nutrition and fluid because it is the most natural and least invasive method. If the patient is able to tolerate oral intake and has adequate oral intake, it is typically the preferred route. Only if she is unable to meet her nutritional needs orally or has difficulty swallowing, then alternative routes such as nasogastric tube, gastrostomy tube, or intravenous routes may be considered. It's important to promote oral intake whenever possible to maintain the patient's quality of life and prevent complications associated with more invasive methods.

Correct Answer: C

Rationale: The patient's presentation of thyroid nodule with compression symptoms like difficulty swallowing and breathing, along with fine-needle aspiration biopsy showing a follicular pattern and colloid-filled spaces, is highly suggestive of a follicular adenoma. Follicular adenomas are benign thyroid tumors that can cause compression symptoms due to their growth and size, leading to pressure on surrounding structures in the neck area. The presence of colloid-filled spaces in the biopsy is characteristic of follicular adenomas.

Correct Answer: A

Rationale: Nurse Nilda immediately responds to any cry from her pediatric patients to attend to her patients who cannot communicate verbally. Crying is one of the few ways infants and young children communicate their needs and discomforts. By responding promptly to their cries, Nurse Nilda can assess and address potential issues such as hunger, pain, discomfort, or other needs that the child may have. This enhances the quality of care provided and helps in comforting and soothing the child, ultimately promoting their well-being and building trust between the nurse and the patient.

Correct Answer: B

Rationale: Assisting the client to a seated position on the toilet should be implemented first. This position promotes relaxation of the pelvic floor muscles and can help facilitate urinary elimination. It is a non-invasive and least intrusive intervention compared to performing intermittent catheterization or administering diuretic medication. Encouraging the client to drink plenty of fluids is important for promoting overall urinary function, but in this case, the priority is to aid the client in attempting to void first.

Correct Answer: B

Rationale: Acknowledging the patient's emotions and offering empathy and support is the most appropriate response in this situation. It is important for the nurse to show understanding and compassion towards the patient, especially when they are feeling emotional about a recent diagnosis. By acknowledging the patient's emotions, the nurse can create a supportive environment that facilitates open communication and helps the patient feel heard and valued. This approach can also help build trust between the patient and the nurse, leading to better outcomes in terms of patient care and overall well-being. Ignoring the patient's emotions, telling them to stop being emotional, or changing the subject may make the patient feel dismissed or isolated, which could negatively impact their mental and emotional state. Thus, offering empathy and support is key in helping the patient cope with their emotions and navigate through their diagnosis.