Adult Health Nursing Answer Key

Correct Answer: C

Rationale: When examining a child, especially one who may already be feeling scared or uncomfortable, it is important to prioritize the order of procedures to help maintain their cooperation and reduce their anxiety. Undressing the child is typically done first to ensure a thorough examination can be performed, and it is a less invasive procedure compared to others. Inspection of the throat with a throat stick and inspection of the ears with an otoscope are common procedures that may cause mild discomfort but are often tolerated well by children. Auscultation of the heart is usually done after these initial steps and is not typically as uncomfortable or frightening for children compared to other procedures. Therefore, auscultation of the heart should not be the last thing to do when examining a child to avoid frightening them.

Correct Answer: D

Rationale: The context of a verbal communication is the environment or situation in which the communication takes place. It includes factors such as the physical setting, the social or cultural background, the relationship between the speaker and the listener, and any other relevant conditions that may impact the understanding of the message. Understanding the context is essential for effective communication as it helps to interpret the meaning behind the words spoken and ensures that the message is appropriately received.

Correct Answer: C

Rationale: In ALS (Amyotrophic Lateral Sclerosis), communication difficulties may occur as the disease progresses and affects the muscles responsible for speech. It is crucial to initiate early measures to assist the patient in communicating effectively. Using pre-signals before the loss of speech can be helpful in maintaining communication with the patient. These pre-signals can include gestures, writing tools, communication boards, or technology-assisted communication devices. By introducing and practicing these pre-signals early on, the patient can adapt and utilize alternative communication methods before the loss of speech becomes more challenging. This proactive approach can significantly improve the patient's ability to communicate and maintain a sense of connection with others.

Correct Answer: A

Rationale: The patient's presentation with grouped vesicles on an erythematous base affecting the lips and perioral region, triggered by sunlight exposure and stress, is classic for herpes simplex labialis, commonly known as cold sores. Herpes simplex virus type 1 (HSV-1) is responsible for cold sores and is highly contagious. Recurrent episodes can be triggered by factors like UV exposure, stress, illness, and hormonal changes. Symptoms typically start with tingling or burning sensations before progressing to grouped vesicles that rupture, forming crusts. Treatment may involve antiviral medications to reduce the severity and duration of symptoms. Perioral dermatitis typically presents with papules and pustules around the mouth, while angular cheilitis involves fissures and inflammation at the corners of the mouth. Allergic contact dermatitis would present with erythema, pruritus, and possibly vesicles in

Correct Answer: B

Rationale: Autonomy is the ethical principle that respects an individual's right to make their own decisions about their medical treatment, even if it goes against medical advice or the preferences of others. In this case, the 70-year-old patient has voluntarily decided not to have the pacemaker inserted despite the physician's recommendation. The fact that the patient's decision is respected by the family reflects the importance of honoring the patient's autonomy and right to make decisions about their own healthcare.