Adult Health Nursing Answer Key

Correct Answer: B

Rationale: When one has Cushing's disease, the focal structure affected is the pituitary gland. Cushing's disease is caused by the overproduction of adrenocorticotropic hormone (ACTH) by the pituitary gland. This excess ACTH stimulates the adrenal glands to produce too much cortisol, leading to the symptoms associated with Cushing's disease. Therefore, the primary issue originates in the pituitary gland, not the other structures mentioned in the question.

Correct Answer: A

Rationale: The patient's presentation with grouped vesicles on an erythematous base affecting the lips and perioral region, triggered by sunlight exposure and stress, is classic for herpes simplex labialis, commonly known as cold sores. Herpes simplex virus type 1 (HSV-1) is responsible for cold sores and is highly contagious. Recurrent episodes can be triggered by factors like UV exposure, stress, illness, and hormonal changes. Symptoms typically start with tingling or burning sensations before progressing to grouped vesicles that rupture, forming crusts. Treatment may involve antiviral medications to reduce the severity and duration of symptoms. Perioral dermatitis typically presents with papules and pustules around the mouth, while angular cheilitis involves fissures and inflammation at the corners of the mouth. Allergic contact dermatitis would present with erythema, pruritus, and possibly vesicles in

Correct Answer: B

Rationale: The correct answer is to avoid sharing items used by the infected person in order to prevent the spread of Scabies infestation to other residents in the community. Scabies is a highly contagious skin infestation caused by the Sarcoptes scabiei mite, and it can easily spread through direct skin-to-skin contact or by sharing personal items such as clothing, towels, and bedding. By advising the family to avoid sharing items used by the infected person, Nurse Emma is helping to prevent the transmission of the mites to others in the community. Boiling utensils, taking excessive baths, or wearing masks and shields are not necessary preventive measures for scabies infestation.

Correct Answer: B

Rationale: When a woman in active labor experiences persistent fetal malposition, such as a transverse lie presentation, assisting the mother into a hands-and-knees position is a nursing intervention to prioritize. This position can help encourage the fetus to rotate into a more favorable position for delivery, such as a head-down position. By placing the mother in a hands-and-knees position, gravity can assist in shifting the fetus to the correct position. This intervention is non-invasive and can be effective in promoting the progress of labor and avoiding the need for more invasive interventions like instrumental delivery or cesarean section. However, if the fetus does not rotate or if there are signs of fetal distress, further interventions may be necessary.

Correct Answer: C

Rationale: When the nurse interacts with patients face-to-face to gather information during the assessment phase of the nursing process, the level of communication is considered interpersonal. Interpersonal communication involves two or more individuals who are connected in a meaningful way. In this scenario, the nurse and the patient are engaging in a personal exchange of information, thoughts, and feelings. This type of communication is essential in building rapport, understanding the patient's needs, and providing effective care. It focuses on creating a supportive and therapeutic relationship between the nurse and the patient, which is crucial for delivering high-quality nursing care.