Adult Health Nursing Study Guide Answers

Correct Answer: B

Rationale: The appropriate nursing action in this situation would be to distract the patient's attention. When a patient perceives that others are talking about them, it may indicate feelings of paranoia or anxiety. It's important to help the patient refocus on something else to alleviate their distress. Distracting the patient's attention can help calm them down and allow the blood pressure measurement to proceed smoothly. This approach respects the patient's feelings and helps manage the situation effectively.

Correct Answer: D

Rationale: Thyroid nodules are abnormal growths of thyroid cells that form a lump within the thyroid gland. When a thyroid nodule becomes large enough, it can cause compressive symptoms such as difficulty swallowing and breathing. The presence of colloid nodules on fine-needle aspiration biopsy indicates a benign and common type of thyroid nodule. In this case, the symptoms are likely due to the physical pressure exerted by the thyroid nodule, rather than an underlying endocrine disorder like Hashimoto's thyroiditis, Graves' disease, or diabetes mellitus. Therefore, the most likely cause of the patient's symptoms is the thyroid nodule itself.

Correct Answer: A

Rationale: Having a tracheostomy means that a patient has an artificial opening in their neck to help them breathe. Therefore, any issues related to breathing, such as blockages in the tracheostomy tube or difficulty in clearing secretions, can pose a major problem for a patient with a tracheostomy. It is crucial to monitor the patient's respiratory status closely and intervene promptly if any breathing difficulties arise to prevent potential respiratory distress or complications.

Correct Answer: A

Rationale: The patient is most likely experiencing autonomic dysreflexia. Autonomic dysreflexia is a potentially life-threatening condition that can occur in individuals with spinal cord injuries at the level of T6 or above. It is characterized by a sudden onset of severe hypertension, bradycardia, diaphoresis, flushing, and headache in response to a noxious stimulus below the level of injury. The sudden change in position from supine to sitting likely triggered autonomic dysreflexia in this patient.

Correct Answer: A

Rationale: After activating the emergency response system, the immediate priority in CPR is to begin chest compressions to support blood circulation. High-quality chest compressions are crucial in providing oxygen to vital organs, especially the brain, during cardiac arrest. Starting chest compressions promptly can improve the chances of survival for the person in need of CPR. Checking for breathing, performing abdominal thrusts, or assessing pulse should only be done after initiating chest compressions in the CPR sequence.