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: Methotrexate is a medication commonly used in the treatment of rheumatoid arthritis. It is known to have potential hepatotoxic effects, meaning it can harm the liver. Monitoring liver function tests (such as alanine aminotransferase (ALT), aspartate aminotransferase (AST), and bilirubin levels) is essential to detect any liver damage early on during methotrexate therapy. By closely monitoring liver function tests, healthcare providers can assess the medication's impact on the liver and determine if any dose adjustments or discontinuation of the drug is necessary to prevent further liver damage. Regular monitoring of liver function tests helps ensure the safe and effective use of methotrexate in patients with rheumatoid arthritis.

Correct Answer: A

Rationale: The appropriate nursing intervention in this case is to encourage the mother to walk to facilitate labor progression. The patient is in early labor with contractions every 5 minutes, lasting 45 seconds each, and her cervix is dilated to 3 cm. Encouraging the mother to walk can help gravity assist the descent of the baby and promote cervical dilation. Walking can also help alleviate some discomfort and encourage labor progression. It is important to promote natural, non-invasive methods to support the progress of labor before considering medical interventions such as oxytocin or cesarean section. Relaxation techniques can also be beneficial in managing pain during labor.

Correct Answer: B

Rationale: The appropriate nursing action in this situation would be to distract the patient's attention. When a patient perceives that others are talking about them, it may indicate feelings of paranoia or anxiety. It's important to help the patient refocus on something else to alleviate their distress. Distracting the patient's attention can help calm them down and allow the blood pressure measurement to proceed smoothly. This approach respects the patient's feelings and helps manage the situation effectively.

Correct Answer: D

Rationale: COPD (Chronic Obstructive Pulmonary Disease) patients often struggle with breathing difficulties due to their conditions, hence it is important for them to conserve their energy as much as possible. Standing while performing activities like shaving or combing hair can be physically demanding for COPD patients as it requires more energy and can lead to increased shortness of breath. It is recommended for COPD patients to sit down or assume a supported position (like the tripod position with elbows supported on a table) to reduce the energy expended and minimize the strain on their respiratory system. Standing in front of the mirror while performing grooming activities is a task that can be easily modified to a seated position, thus conserving energy and reducing the risk of exacerbating breathing difficulties for COPD patients.