Adult Health Nursing First Chapter Quizlet

Correct Answer: C

Rationale: Assessing the patient for respiratory distress is the important nursing intervention that must be done in this situation. The scenario provided indicates that the patient with chronic obstructive pulmonary disease (COPD) is experiencing increased work of breathing, which puts them at risk for respiratory distress. It is crucial for the nurse to monitor the patient's respiratory status closely, including assessing their oxygen saturations, respiratory rate, and effort, to identify any signs of respiratory distress early and intervene promptly. This proactive assessment can help prevent further deterioration of the patient's condition and ensure appropriate nursing interventions are implemented promptly.

Correct Answer: C

Rationale: Antipsychotic medications, especially first-generation antipsychotics, can cause extrapyramidal symptoms (EPS) as an adverse effect. EPS include symptoms such as muscle rigidity, tremors, akathisia (restlessness), and tardive dyskinesia (involuntary movements of the face and body). These symptoms are due to the medications' effects on the dopamine system in the brain. It is crucial for the nurse to monitor the patient closely for EPS because they can be uncomfortable, distressing, and may impact the patient's quality of life and medication adherence. Early recognition and management of EPS are essential to prevent further complications and improve the patient's overall well-being.

Correct Answer: C

Rationale: Cervical intraepithelial neoplasia (CIN) is a premalignant condition of the cervix that is characterized by the presence of high-risk human papillomavirus (HPV) types. HPV infection is a major risk factor for the development of cervical cancer. CIN is typically detected on routine cervical screening tests such as Pap smears or HPV testing. If left untreated, CIN can progress to invasive cervical cancer. Therefore, the presence of high-risk HPV types in CIN lesions indicates an increased risk of developing cervical cancer.

Correct Answer: A

Rationale: The presentation described is characteristic of acute angle-closure glaucoma. This condition typically presents with sudden-onset severe eye pain, headache, nausea, and vomiting. On examination, the affected eye may appear red due to conjunctival injection, and there may be a steamy cornea due to corneal edema. The mid-dilated, non-reactive pupil is a key finding in angle-closure glaucoma, as the iris bombe (forward movement of the peripheral iris) blocks the drainage angle, leading to increased intraocular pressure. If left untreated, acute angle-closure glaucoma can result in irreversible vision loss. Immediate intervention is crucial to lower the intraocular pressure and prevent further damage to the optic nerve. Prompt referral to an ophthalmologist for definitive treatment is necessary in cases of suspected acute angle-closure glaucoma.

Correct Answer: C

Rationale: When a nurse discovers a discrepancy between the medication order and the patient's medication record, the priority action is to verify the medication order with the prescriber to ensure accuracy and patient safety. Administering the medication without clarification can put the patient at risk. Documenting the discrepancy and informing the charge nurse is important, but it should not delay verifying the order with the prescriber. Contacting the pharmacy for clarification may be necessary in some cases, but the immediate action should be to confirm the prescription with the prescriber to prevent errors and ensure the patient receives the correct medication.