Adult Health Nursing Study Guide Answers

Correct Answer: A

Rationale: The first priority for a nurse caring for a patient experiencing a seizure is safety. Ensuring the safety of the patient is crucial to prevent injury during the seizure episode. This includes clearing the area around the patient of any harmful objects, preventing the patient from falling or hitting their head, placing them in a safe position to prevent aspiration if they vomit, and staying with the patient until the seizure ends. Once the patient is safe, the nurse can then focus on other aspects of care such as assessing airway, providing emotional support, and monitoring for complications.

Correct Answer: C

Rationale: Checking the humidifier's water regularly is the priority precautionary measure that should be done by the nurse during oxygen therapy. Maintaining adequate water in the humidifier ensures proper humidification of the oxygen delivered to the patient, helping prevent mucous membrane dryness and irritation. Dry mucous membranes can lead to discomfort, increased risk of infection, and potential damage to the respiratory system. Therefore, ensuring the humidifier's water level is appropriate is crucial for the safety and well-being of the patient receiving oxygen therapy. Limiting visitors, attaching "No Smoking" signage, and connecting the bait to the oxygen tank are important precautions as well, but checking the humidifier's water is the priority measure in this scenario.

Correct Answer: C

Rationale: Sudden, severe chest pain and dyspnea in a postpartum client could be indicative of a potential serious condition, such as a pulmonary embolism or postpartum cardiomyopathy, which require immediate medical attention. Therefore, the most appropriate nursing action would be to notify the healthcare provider immediately for further evaluation and management. Placing the client in a semi-Fowler's position may provide some comfort but does not address the underlying cause of the symptoms. Administering supplemental oxygen therapy may be necessary once the healthcare provider assesses the client. Encouraging deep breathing exercises may not be appropriate if the client is experiencing severe chest pain and dyspnea, as it could worsen the situation.

Correct Answer: B

Rationale: Pelvic inflammatory disease (PID) is the most likely cause of the symptoms described in the pregnant woman. PID is an infection of the female reproductive organs, typically caused by sexually transmitted bacteria like Chlamydia or Gonorrhea. The classic presentation includes lower abdominal pain, fever, vaginal discharge, cervical motion tenderness, and bilateral adnexal tenderness on examination. This condition can lead to serious complications if not promptly treated, including infertility, ectopic pregnancy, and chronic pelvic pain. Therefore, it is crucial to diagnose and manage PID promptly, especially in pregnant women, to prevent adverse outcomes.

Correct Answer: B

Rationale: The gallbladder is the structure responsible for storing and concentrating bile produced by the liver until it is needed for digestion. Bile is a digestive fluid that helps in the breakdown of fats during the digestive process. When food containing fats enters the small intestine, the gallbladder contracts and releases bile into the small intestine to aid in the digestion and absorption of fats. The gallbladder acts as a reservoir for bile, storing it until it is needed for digestion.