Adult Health Nursing Answer Key

Correct Answer: C

Rationale: In ALS (Amyotrophic Lateral Sclerosis), communication difficulties may occur as the disease progresses and affects the muscles responsible for speech. It is crucial to initiate early measures to assist the patient in communicating effectively. Using pre-signals before the loss of speech can be helpful in maintaining communication with the patient. These pre-signals can include gestures, writing tools, communication boards, or technology-assisted communication devices. By introducing and practicing these pre-signals early on, the patient can adapt and utilize alternative communication methods before the loss of speech becomes more challenging. This proactive approach can significantly improve the patient's ability to communicate and maintain a sense of connection with others.

Correct Answer: A

Rationale: The symptoms of irritability, muscle weakness, tremors, weight loss despite increased appetite, along with elevated serum thyroid hormone levels and suppressed TSH levels, are indicative of hyperthyroidism. In hyperthyroidism, the thyroid gland produces an excess amount of thyroid hormone, leading to an overactive metabolism. This results in symptoms such as weight loss, tremors, irritability, and muscle weakness. The elevated levels of thyroid hormone are detected in the laboratory tests, along with low TSH levels due to negative feedback regulation. Therefore, the most likely endocrine disorder responsible for these symptoms is hyperthyroidism.

Correct Answer: C

Rationale: The appropriate and recommended site for insulin injection to help avoid hypoglycemia is the abdominal wall subcutaneously. This site offers a consistent and reliable rate of absorption of insulin into the bloodstream. By injecting insulin into the abdominal wall subcutaneously, it allows for better control of blood sugar levels and reduces the risk of hypoglycemia. Additionally, it is important to rotate injection sites within the chosen area to prevent the development of lipohypertrophy (thickened, rubbery areas under the skin), which can affect insulin absorption.

Correct Answer: A

Rationale: Proper latch technique is the most important nursing intervention to alleviate nipple soreness in a breastfeeding client. When a baby latches on correctly, it helps prevent nipple trauma and soreness. Educating the client on how to achieve a proper latch, such as ensuring the baby's mouth covers both the nipple and areola, can significantly reduce discomfort during feedings. Improving the latch can also enhance milk transfer, leading to better breastfeeding outcomes for both the mother and baby. While lanolin cream (choice C) can provide some relief for sore nipples, addressing the root cause by correcting the latch is crucial for long-term comfort and successful breastfeeding. Using nipple shields (choice B) or encouraging the use of breast pumps (choice D) should not be the first line of intervention when addressing sore nipples, as they do not address the underlying issue of latch technique.

Correct Answer: C

Rationale: The presence of ecchymosis (bruising) and significant swelling in the perineum despite analgesic medication suggests a potential complication such as a hematoma. A hematoma is a collection of blood that can occur due to trauma or during childbirth. It is important to notify the healthcare provider immediately so that further assessment and interventions, such as drainage of the hematoma, can be initiated promptly to prevent complications and alleviate the client's pain. Applying ice packs or encouraging the client to sit on a donut cushion may provide temporary relief but will not address the underlying issue of a potentially serious hematoma. Administering additional analgesic medication may not be effective in this case if the pain is primarily due to the hematoma. Prompt notification of the healthcare provider is crucial for proper management of this situation.