Adult Health Nursing Study Guide Answers

Correct Answer: D

Rationale: When performing an admission assessment, the nurse should expect to find clinical manifestations that are indicative of a variety of conditions. Paresthesia (abnormal sensation like tingling, prickling, or numbness) and muscle weakness of the upper body are commonly associated with neurological conditions such as peripheral neuropathy or cervical radiculopathy. These symptoms suggest dysfunction in the nerves that supply the upper body muscles, leading to sensory changes and weakness. This finding would prompt further assessment and evaluation by healthcare providers to determine the underlying cause and appropriate interventions. Rapid progressive muscular atrophy, ascending paralysis with ataxia, and hyperactive deep tendon reflexes are not typically expected findings during an admission assessment and may signal more specific neurological conditions such as amyotrophic lateral sclerosis, Guillain-Barré syndrome, or spinal cord injury, respectively.

Correct Answer: B

Rationale: In a pregnant woman presenting with severe abdominal pain and vaginal bleeding at 8 weeks gestation with a closed cervix, the most likely cause of these symptoms is a threatened abortion. A threatened abortion is a common complication of early pregnancy characterized by vaginal bleeding and lower abdominal pain without cervical dilation. The cervix remains closed, indicating that the pregnancy is still intact but at risk of potential miscarriage. Placenta previa typically presents with painless vaginal bleeding in the second or third trimester, whereas ectopic pregnancy usually presents with abdominal pain and vaginal bleeding in the setting of a closed cervix but is less likely at 8 weeks gestation. Gestational trophoblastic disease is a rare cause of vaginal bleeding in pregnancy and typically presents in the first trimester with signs of hyperemesis gravidarum, uterine enlargement, and elevated β-hCG levels.

Correct Answer: C

Rationale: Ménière's disease is characterized by the triad of symptoms including progressive sensorineural hearing loss, tinnitus, and vertigo. The audiometric testing in Ménière's disease often shows a "carrot-shaped" configuration, which refers to low-frequency hearing loss initially and eventually spreading to involve higher frequencies. This distinctive pattern of hearing loss helps differentiate Ménière's disease from other causes like Presbycusis (age-related hearing loss) or Noise-induced hearing loss. Acoustic neuroma can present with unilateral sensorineural hearing loss but typically does not exhibit the specific "carrot-shaped" configuration seen in Ménière's disease.

Correct Answer: A

Rationale: The patient's presentation of fatigue, weakness, jaundice, elevated indirect bilirubin levels, reticulocytosis, and positive Coombs test is consistent with hemolytic anemia. Among the options provided, hereditary spherocytosis is the most likely condition to cause these findings.

Correct Answer: C

Rationale: The nurse should prioritize checking the patency of the NG tube by aspirating gastric contents before initiating tube feeding. This is important to ensure that the NG tube is in the correct position and that it is functioning properly. By aspirating gastric contents, the nurse can confirm that the tube is in the stomach and not in the lungs or surrounding tissues. If no gastric contents are obtained upon aspiration, it may indicate that the tube is not properly placed or may be occluded, which would require further assessment and intervention before proceeding with tube feeding. Checking the patency of the NG tube is a crucial step in ensuring the safety and effectiveness of enteral nutrition delivery.