Adult Health Nursing Answer Key

Correct Answer: B

Rationale: Major histocompatibility complex (MHC) class I molecules are responsible for presenting endogenous antigens, such as viral or intracellular proteins, to CD8+ T cells. These antigens are derived from within the cell, either synthesized within the cell itself or taken up from the cytoplasm. CD8+ T cells, also known as cytotoxic T cells, recognize antigens presented by MHC class I molecules and play a key role in cell-mediated immunity by destroying infected or abnormal cells.

Correct Answer: B

Rationale: The presence of risk factors indicates an increased likelihood or susceptibility to developing a particular disease. While risk modification and healthy lifestyle choices can help reduce the risk, having these risk factors still increases the overall chances of getting the disease compared to individuals without the same risk factors. It is essential for individuals with risk factors to be proactive in managing their health to mitigate the increased risk.

Correct Answer: A

Rationale: The clinical presentation described is highly suggestive of acute angle-closure glaucoma. This condition typically presents with sudden-onset severe eye pain, headache, nausea, and vomiting. The red eye, steamy cornea (due to corneal edema), and mid-dilated, non-reactive pupil (from the unopposed force of the dilator muscle) are classic findings in acute angle-closure glaucoma. The increase in intraocular pressure compromises blood flow to the eye, leading to symptoms of blurred vision and possible visual loss. Immediate management usually involves lowering intraocular pressure with medications or surgical intervention to prevent vision loss. Central retinal artery occlusion, optic neuritis, and corneal ulcer typically present with different clinical features and are not consistent with the described presentation.

Correct Answer: D

Rationale: During the first contact with a patient, a nurse should demonstrate caring, encouraging, and comforting behaviors. These qualities help create a positive and supportive environment for the patient. However, compelling behavior, which implies forcing or pressuring someone to do something, is not appropriate during the initial interaction with a patient. It is essential for the nurse to build trust and rapport with the patient, and compelling behavior can be counterproductive to establishing a nurturing relationship. Thus, compelling is the exception among the given choices for the nurse's behavior during the first contact with a patient.

Correct Answer: A

Rationale: Benign prostatic hyperplasia (BPH) can lead to urinary retention, which is a common complication associated with this condition. As the prostate gland enlarges, it can obstruct the flow of urine from the bladder through the urethra. This obstruction can result in difficulty starting to urinate, weak urine flow, frequent urination, incomplete bladder emptying, and eventually urinary retention. If left untreated, urinary retention can lead to serious complications such as urinary tract infections, bladder damage, kidney damage, and even kidney stones. Therefore, urinary retention is an important complication to be aware of in patients with BPH.