Adult Health Nursing Answer Key

Correct Answer: B

Rationale: The patient can tell all information to the nurse once the feeling of security is established in the nurse-patient relationship. Open communication and sharing of information are essential components of nursing care. Patients are more likely to disclose personal information, concerns, and feelings when they trust their nurse and feel secure in the relationship. Building trust and creating a safe and supportive environment are crucial for effective therapeutic communication and holistic patient care. It is important for the nurse to establish a trusting relationship with the patient to encourage open communication and provide patient-centered care.

Correct Answer: A

Rationale: The patient's presentation of gradual-onset memory loss, confusion, difficulty with complex tasks, disorientation, and functional decline are all classic features of Alzheimer's disease. Alzheimer's disease is a progressive neurodegenerative disorder characterized by the accumulation of abnormal protein deposits in the brain, leading to widespread neuronal damage and cognitive decline. As the disease progresses, patients typically experience worsening memory loss, cognitive impairment, and deficits in activities of daily living, ultimately requiring full-time care and assistance. Other neurodegenerative diseases such as Parkinson's disease, Huntington's disease, and frontotemporal dementia may present with cognitive impairment and behavioral changes, but the specific constellation of symptoms described in the case is most indicative of Alzheimer's disease.

Correct Answer: A

Rationale: The patient's presentation with a blood sugar level of 800mg/dL, absence of ketones in the urine, dehydration, and altered mental status points towards Hyperosmolar nonketotic coma (HNKC). HNKC typically occurs in patients with Type 2 diabetes and is characterized by extremely high blood glucose levels (hyperglycemia) without significant ketosis. The absence of ketones in the urine distinguishes HNKC from Diabetic ketoacidosis (DKA). Patients with HNKC often present with severe dehydration, altered mental status, and hyperosmolarity. It is crucial to address the underlying cause of the hyperglycemia, correct dehydration, and normalize blood glucose levels promptly in the management of HNKC.

Correct Answer: C

Rationale: Following surgical fixation of a tibial shaft fracture with an intramedullary nail, healthcare providers should monitor for the development of fat embolism syndrome (FES) in the immediate postoperative period. FES is a serious complication that occurs when fat droplets from the bone marrow enter the bloodstream and cause respiratory and neurological symptoms. Clinical manifestations of FES may include dyspnea, tachypnea, petechial rash, altered mental status, and hypoxemia. Prompt recognition and treatment are essential in managing fat embolism syndrome to prevent serious complications such as respiratory failure and neurological deficits. Monitoring for signs and symptoms of FES is crucial in the postoperative care of patients undergoing surgical fixation of long bone fractures.

Correct Answer: C

Rationale: In situations where a patient's family member is expressing anxiety about their loved one's condition, it is important for the nurse to provide clear and accurate information about the patient's status. By explaining the nature of the injury and reassuring the wife that her husband's condition is stable, the nurse can help alleviate her anxiety and address her concerns in a meaningful way. This intervention focuses on open communication and providing emotional support, which are crucial in helping the family member cope with the situation. It is essential to establish trust and create a supportive environment for the family member during this stressful time.