Adult Health Nursing Study Guide Answers

Correct Answer: C

Rationale: The correct response is "Because of the normal pooling of blood in the vagina when the woman lies down to rest or sleep." This phenomenon occurs due to gravity when a woman lies down, and the blood tends to pool at the top of the vagina. When she first arises from bed, the pooled blood is released, resulting in a gush of blood. This is a normal physiological process and not typically a cause for concern.

Correct Answer: A

Rationale: The best thing to do next is to turn off the fan immediately. The fact that the electric fan is stopping every now and then and sparking at intervals indicates a potential electrical issue or malfunction. This situation poses a safety hazard as it increases the risk of an electrical fire or damage to the fan. Turning off the fan immediately will help prevent any further damage or potential danger. After turning off the fan, it would be advisable to call for maintenance to inspect and repair the fan to ensure it is safe to use again.

Correct Answer: D

Rationale: The clinical presentation of chest pain, dyspnea, and a friction rub heard on auscultation is suggestive of pericarditis. The diffuse ST-segment elevation seen on the electrocardiogram (ECG) is a classic finding in pericarditis, known as the "universal sign." In contrast, stable angina typically presents with chest pain on exertion that is relieved by rest or nitroglycerin, while unstable angina presents with chest pain at rest or with minimal exertion. Acute myocardial infarction would typically present with ST-segment elevation in specific leads correlating with the area of myocardial ischemia/infarction. However, in the context of diffuse ST-segment elevation and symptoms suggestive of inflammation (friction rub), the most likely diagnosis is pericarditis.

Correct Answer: A

Rationale: Natural killer (NK) cells play a vital role in the innate immune response by identifying and eliminating virus-infected cells, as well as tumor cells, without the need for prior exposure or activation. NK cells are able to detect abnormal cells by recognizing changes in the cell surface molecules, such as downregulation of MHC class I molecules. Once activated, NK cells release cytotoxic granules containing perforin and granzyme, leading to the destruction of the target cell. This direct killing mechanism is crucial for controlling viral infections and preventing the development of tumors. NK cells do not produce antibodies (option B), present antigens to T cells (option C), or release cytokines to recruit other immune cells (option D) as their primary function in the immune response.

Correct Answer: C

Rationale: In the provided scenario, the patient is scheduled for Lithotripsy under spinal anesthesia. This means that the nurse needs to communicate with the department of anesthesia to coordinate and prepare for the procedure. Anesthesia departments are responsible for administering various types of anesthesia, including spinal anesthesia, to ensure patients are comfortable and pain-free during medical procedures. Therefore, contacting the department of anesthesia is crucial in this situation to ensure that the necessary arrangements are in place for the patient's lithotripsy procedure.