Adult Health Nursing Quizlet Final

Correct Answer: A

Rationale: Difficulty of speaking and chewing is an indicator of cranial nerve involvement. Cranial nerves are responsible for controlling various functions of the head and neck, including speech and mastication. Impairment of cranial nerve function can lead to difficulty in these activities. In the context of the question, with the patient in the stroke unit, cranial nerve involvement can occur due to the stroke affecting the brain regions responsible for cranial nerve function. Loss of pain sensation, spastic paralysis of the extremities, and forgetfulness with syncope are not specific indicators of cranial nerve involvement in this scenario.

Correct Answer: A

Rationale: When a patient is prescribed with an angiotensin-converting enzyme (ACE) inhibitor for managing hypertension, the nurse should monitor closely for signs of hyperkalemia. ACE inhibitors can affect the renin-angiotensin-aldosterone system, leading to decreased aldosterone secretion and impaired potassium excretion by the kidneys. As a result, potassium levels in the blood may increase, leading to hyperkalemia.

Correct Answer: D

Rationale: The desired nursing action to help the pregnant patient make a decision on breastfeeding is to assist in identifying a breastfeeding goal and plan. When patients are indecisive about breastfeeding, it is essential for the nurse to support them in setting specific goals and creating a plan that aligns with their values and circumstances. This approach can help the patient feel empowered and confident in their decision-making process. Providing pamphlets and books (choice A) may be helpful, but personalized assistance in identifying a breastfeeding goal and plan is more likely to address the patient's individual needs and concerns. Providing ample time for the patient to decide (choice B) is important, but guidance and support in setting a clear goal can facilitate the decision-making process. Referring the patient to a nutritionist (choice C) may be beneficial for dietary concerns but may not directly address the decision-making process regarding breastfeeding.

Correct Answer: D

Rationale: In research involving adults who are capable of providing informed consent, such as a 21-year-old subject, the absolute way to ensure autonomy and respect for the individual's rights is to obtain informed and written consent directly from the subject herself. The subject's autonomy and right to self-determination should be respected, and obtaining consent directly from the subject ensures that they are fully informed about the research, its risks, benefits, and their rights regarding anonymity and confidentiality. In this case, Nurse Carmi must explain the research process clearly to the 21-year-old subject, obtain her informed consent in writing, and ensure that her anonymity, confidentiality, and human rights are protected throughout the study.

Correct Answer: B

Rationale: Option B is the most appropriate response when addressing a postpartum client's concerns about resuming sexual activity after a vaginal delivery. Educating the client about the normal changes in sexual desire and response following childbirth can help alleviate anxiety and provide reassurance. It is crucial for the nurse to explain that it is common for women to experience changes in libido, physical discomfort, and emotional adjustments after giving birth. By discussing these normal postpartum changes, the nurse can support the client in understanding that her feelings are valid and that it may take time for her to feel ready to engage in sexual activity again. Furthermore, the nurse can provide information on ways to enhance comfort and intimacy when resuming sexual activity, such as communication with partners, using lubricants, and gradually easing back into sexual activity as desired.