Adult Health Nursing Study Guide Answers

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: A

Rationale: When planning for a client's care, a primary consideration is to prevent problems related to immobility. Immobility can lead to a range of complications such as pressure ulcers, muscle weakness, joint contractures, and decreased circulation. To maintain the client's overall health and well-being, it is essential to address mobility issues and implement strategies to prevent complications associated with immobility. By prioritizing interventions that promote movement and prevent immobility-related problems, the client's quality of life can be improved and potential health risks mitigated.

Correct Answer: A

Rationale: The description of multiple flesh-colored papular lesions with a central dell that tend to bleed upon minor trauma and have been increasing in number over time is characteristic of basal cell carcinoma. Basal cell carcinoma is the most common type of skin cancer and typically presents as pearly or flesh-colored papules with telangiectasias (tiny blood vessels) and a characteristic central dell or ulceration. This type of skin cancer often occurs on sun-exposed areas like the face and trunk and can manifest as slow-growing lesions that may bleed easily with minor trauma. In contrast, squamous cell carcinoma typically presents as a scaly or crusted lesion, seborrheic keratosis is a benign skin growth with a waxy, stuck-on appearance, and actinic keratosis is a precancerous lesion characterized by rough, scaly patches on sun-exposed areas.

Correct Answer: A

Rationale: The patient is most likely experiencing autonomic dysreflexia. Autonomic dysreflexia is a potentially life-threatening condition that can occur in individuals with spinal cord injuries at the level of T6 or above. It is characterized by a sudden onset of severe hypertension, bradycardia, diaphoresis, flushing, and headache in response to a noxious stimulus below the level of injury. The sudden change in position from supine to sitting likely triggered autonomic dysreflexia in this patient.

Correct Answer: C

Rationale: Reflecting the patient's feelings and expressions is a therapeutic communication technique that involves mirroring back the patient's emotions and thoughts. By doing this, the nurse validates the patient's experiences and helps them explore their feelings further. This technique can enhance the patient's self-awareness and promote emotional expression, leading to a deeper understanding of their conflicting emotions. Offering advice (Option A) may not be as effective because the focus should be on helping the patient process their own emotions. Providing reassurance and false hope (Option B) can hinder the patient's emotional exploration and may lead to trust issues if the reality does not align with the false reassurance. Redirecting the conversation to a different topic (Option D) avoids addressing the patient's conflicting emotions, which is crucial for therapeutic communication and support.