Adult Health Nursing First Chapter Quizlet

Correct Answer: B

Rationale: In patients with Rheumatic fever, typical manifestations include an increase in body temperature, non-pruritic rashes, and migratory joint pains. Voluntary muscle spasm is not a typical manifestation of Rheumatic fever. The main clinical features of Rheumatic fever are related to the inflammation of the heart, joints, skin, and central nervous system. Muscle spasms are not a prominent feature of this condition. It is important for the nurse to be aware of these typical manifestations to effectively monitor and manage the patient's condition.

Correct Answer: B

Rationale: Magnesium sulfate is used to prevent eclampsia, but it can lead to toxicity if levels become too high. One common sign of magnesium toxicity is increased deep tendon reflexes, also known as hyperreflexia. This occurs because magnesium is a muscle relaxant, and elevated levels can lead to over-relaxation of muscles, causing an exaggerated reflex response. Other signs of magnesium toxicity include respiratory depression, decreased urine output, and cardiac arrest. Therefore, in a woman receiving intravenous magnesium sulfate during labor, an increase in deep tendon reflexes would indicate potential toxicity and require immediate intervention.

Correct Answer: C

Rationale: The clinical presentation of fever, malaise, maculopapular rash starting on the face and spreading to the trunk and extremities, along with leukopenia and thrombocytopenia, is highly suggestive of Rocky Mountain spotted fever (RMSF) caused by Rickettsia rickettsii. RMSF is a tick-borne illness transmitted by the American dog tick, Rocky Mountain wood tick, and brown dog tick. The constellation of symptoms described aligns well with the typical presentation of RMSF. Borrelia burgdorferi causes Lyme disease, which presents with erythema migrans but does not typically cause leukopenia or thrombocytopenia. Plasmodium falciparum is the causative agent of severe malaria and would present with symptoms such as cyclic fevers, anemia, and jaundice but not the described rash distribution.

Correct Answer: C

Rationale: The initial action the nurse should take when faced with a situation where a patient refuses to take medication after education and explanation is to notify the physician. The physician may need to be informed so they can reassess the medication and potentially explore alternative options or make adjustments based on the patient's concerns and preferences. It is important for medical decisions to be made in collaboration with the healthcare team to ensure the best care for the patient. Consulting the physician also helps in avoiding any potential negative outcomes resulting from the patient's refusal to take the prescribed medication. Once the physician is aware, further actions can be discussed and implemented to address the patient's concerns.

Correct Answer: D

Rationale: When managing a patient with a suspected heat stroke, the appropriate action is to remove the patient from the hot environment and start cooling the body. Heat stroke is a medical emergency that can be life-threatening if not promptly treated. Cooling the body is essential to lower the core body temperature as quickly as possible. Ice packs should not be directly applied to the skin as they can cause vasoconstriction and may actually hinder heat dissipation. Administering warm intravenous fluids and encouraging the patient to drink cold water rapidly are also not recommended in the initial management of a heat stroke. The priority is to cool the patient down and seek medical attention immediately.