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: A

Rationale: The priority nursing intervention in this situation is to first assess the client for signs of urinary retention or bladder distention. Difficulty in emptying the bladder completely and experiencing urinary frequency can be indications of urinary retention, which can lead to bladder distention and possible complications such as urinary tract infection. By assessing the client, the nurse can determine the cause of the issue and implement appropriate interventions. It is crucial to address potential complications promptly to promote the client's health and well-being postpartum. Once the assessment is completed, further interventions such as recommending appropriate measures, like warm compresses or pelvic floor exercises, can be considered based on the assessment findings.

Correct Answer: C

Rationale: An amniotic fluid embolism is a rare and life-threatening complication during labor and delivery. It occurs when amniotic fluid or fetal cells enter the maternal circulation, triggering a rapid immune response that can lead to cardiovascular collapse and respiratory failure. The priority nursing intervention for a woman in active labor diagnosed with an amniotic fluid embolism is to initiate cardiopulmonary resuscitation (CPR) to support her vital functions and circulation. Providing immediate CPR can help sustain her until further medical interventions can be implemented. Administering oxygen and preparing for a cesarean section may be necessary but should occur after CPR is initiated to stabilize the woman's condition. Inserting an indwelling urinary catheter is not the priority in this emergency situation, as maintaining adequate cardiac and respiratory function takes precedence.

Correct Answer: B

Rationale: Cervical intraepithelial neoplasia (CIN) is a precancerous condition of the cervix characterized by the presence of abnormal cells on the surface of the cervix. These abnormal cells are often classified as low-grade squamous intraepithelial lesions (LSIL) on cytology. CIN is not yet cervical cancer but can progress to invasive cancer if left untreated. LSIL is indicative of mild dysplasia or cervical intraepithelial neoplasia 1 (CIN 1), which is considered a precancerous lesion. Therefore, the presence of abnormal cervical cells classified as LSIL is more likely to be associated with CIN rather than cervical cancer, cervicitis, or cervical polyps.

Correct Answer: C

Rationale: By endorsing a detergent product on a TV commercial wearing a mini skirt and a plunging neckline shirt, Ms. Sanchez is violating the code of ethics for nurses. The code of ethics for nurses includes provisions that promote professionalism, respect, and integrity in the nursing profession. As a new nursing graduate, Ms. Sanchez has a responsibility to uphold the dignity and reputation of the nursing profession, and endorsing a product in a manner that may compromise her professional image goes against these principles. Nurses are expected to maintain a professional appearance and behavior that reflects positively on the profession and does not undermine public trust in their abilities as healthcare providers. Therefore, Ms. Sanchez's actions in this scenario are in violation of the code of ethics for nurses.