Adult Health Nursing Answer Key

Correct Answer: C

Rationale: In the early stages of multiple myeloma (MM), abnormal values are often seen in the levels of immunoglobulins. This is due to the abnormal proliferation of plasma cells in the bone marrow, leading to overproduction of monoclonal immunoglobulins (M proteins). These abnormal immunoglobulins can be detected in blood tests and are a key diagnostic feature of MM. Changes in red blood cells, white blood cells, and platelets are not typically early indicators of multiple myeloma.

Correct Answer: B

Rationale: The most appropriate response from the nurse when a patient expresses frustration with the treatment plan proposed by the healthcare team is to empathize with the patient's frustration and explore their concerns further. It is important to actively listen to the patient, acknowledge their feelings, and address any questions or uncertainties they may have about the treatment plan. By engaging in open communication and demonstrating empathy, the nurse can foster a therapeutic relationship with the patient and work towards finding a solution that is mutually agreeable and beneficial for the patient's well-being. Dismissing the patient's concerns (Option A) or ignoring their frustration (Option C) can lead to a breakdown in communication and trust, which may ultimately impact the patient's compliance with the treatment plan. Similarly, telling the patient that they have no choice but to follow the treatment plan (Option D) can be perceived as dismissive and confrontational, which is not conducive to promoting patient-centered care.

Correct Answer: D

Rationale: While all of the nursing measures listed are important considerations when managing a patient receiving oxytocin drip, the nurse would least consider informing the patient about potential complications. The reason for this is that it is the responsibility of the healthcare provider (such as the physician or advanced practice nurse) to inform the patient about potential complications of a medication or treatment. Nurses are instrumental in providing education and support to patients, but in the case of informing patients about potential complications, this task typically falls under the purview of the prescribing provider. The primary focus of the nurse in this situation would be to assess, administer, monitor, and educate the patient as appropriate, ensuring safe and effective care delivery.

Correct Answer: D

Rationale: A nurse should have a sense of accountability for his actions. This means taking responsibility for one's decisions and behaviors while working in the healthcare setting. Accountability ensures that the nurse is aware of the consequences of his actions and is willing to accept ownership and follow through on commitments. It is a critical aspect of nursing practice as it helps maintain professional standards, promote patient safety, and uphold trust and integrity within the profession. Nurses are entrusted with the well-being of their patients, so being accountable for their actions is essential in providing high-quality care and maintaining ethical standards.

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.