It is important that Nurse Chona records accurately the restless caused by pain and that of hypoxia. Which of the following should be recorded as the restlessness caused by pain?

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Adult Health Nursing Quizlet Final Questions

Question 1 of 9

It is important that Nurse Chona records accurately the restless caused by pain and that of hypoxia. Which of the following should be recorded as the restlessness caused by pain?

Correct Answer: D

Rationale: Restlessness caused by pain often manifests as increased perspiration and constant change of position. When a person is in pain, they may become sweaty or clammy due to increased sympathetic nervous system activity. Additionally, they may constantly shift or fidget in an attempt to find a more comfortable position that can alleviate the pain they are experiencing. Therefore, it is crucial for Nurse Chona to accurately document these behaviors as signs of pain-related restlessness. Difficulty of breathing (Option A), increased respiratory rate and blood pressure (Option B), and increased heart rate (Option C) are more indicative of hypoxia or respiratory distress rather than pain-related restlessness.

Question 2 of 9

A patient presents with a small, painless, well-defined nodule on the lateral aspect of the neck, just above the clavicle. Fine-needle aspiration cytology reveals clusters of polygonal cells with abundant granular cytoplasm. Which of the following conditions is most likely responsible for this presentation?

Correct Answer: D

Rationale: The presentation described is characteristic of a parathyroid adenoma. Parathyroid adenomas are benign neoplasms that can present as painless, well-defined nodules usually located in the lower pole of the thyroid gland or in close proximity, such as the lateral aspect of the neck above the clavicle. Fine-needle aspiration cytology of a parathyroid adenoma typically reveals polygonal cells with abundant granular cytoplasm, often referred to as chief cells. This is key in differentiating it from other conditions mentioned in the question.

Question 3 of 9

A nurse is preparing to perform a continuous bladder irrigation (CBI) procedure for a patient following urological surgery. What action should the nurse prioritize to prevent complications during CBI?

Correct Answer: A

Rationale: The nurse should prioritize adjusting the irrigation flow rate based on the patient's urine output to prevent complications during continuous bladder irrigation (CBI). Proper adjustment of the irrigation flow rate helps maintain adequate bladder drainage while preventing bladder distention, clot formation, and potential irrigation fluid overload. Monitoring the patient's urine output and adjusting the flow rate accordingly ensures optimal functioning of the CBI system and enhances patient safety. This proactive approach minimizes the risk of complications and promotes effective postoperative care following urological surgery.

Question 4 of 9

In the care of families, crisis intervention is an important part of _____.

Correct Answer: A

Rationale: Crisis intervention is an important part of secondary prevention in the care of families. Secondary prevention involves activities that aim to reduce the impact of a crisis or event that has already occurred. Crisis intervention provides immediate support and strategies to help families cope with and overcome a crisis situation. By addressing the crisis quickly and effectively, secondary prevention can help prevent further negative outcomes and promote the well-being of the family members.

Question 5 of 9

Nurse Victor assesses patient Mil. Decrease of which the following factors would help detect that the patient is at risk at developing cardiogenic shock?

Correct Answer: B

Rationale: Cardiogenic shock is a life-threatening condition where the heart is unable to pump enough blood to meet the body's demands. Monitoring the patient's cardiac index, which is a measure of cardiac output adjusted for body surface area, can help detect the risk of developing cardiogenic shock. A decrease in cardiac index would indicate a decrease in the heart's ability to effectively pump blood, putting the patient at risk for cardiogenic shock. Monitoring cardiac index is essential in assessing cardiac function and guiding interventions to prevent the progression to cardiogenic shock. The other factors listed may provide important information in assessing the patient's condition, but specifically in detecting the risk of developing cardiogenic shock, monitoring the cardiac index is crucial.

Question 6 of 9

A patient presents with tremors, rigidity, bradykinesia, and postural instability. On examination, the patient demonstrates a shuffling gait, stooped posture, and a masked facies. Which of the following neurological conditions is most likely responsible for these symptoms?

Correct Answer: B

Rationale: The symptoms described in the patient, such as tremors, rigidity, bradykinesia (slow movement), and postural instability, along with the presence of a shuffling gait, stooped posture, and masked facies, are classic features of Parkinson's disease. These motor symptoms are primarily caused by the degeneration of dopamine-producing neurons in the substantia nigra region of the brain. This results in an imbalance of neurotransmitters, particularly dopamine, leading to motor dysfunction and characteristic movement abnormalities seen in Parkinson's disease.

Question 7 of 9

Upon seeing warning signs of child abuse, the BEST nursing action that Nurse Alma should make is to report the noted observation to __________.

Correct Answer: A

Rationale: Reporting observed signs of child abuse to the Department of Social Welfare Development (DSWD) is the best nursing action in cases of suspected child abuse. DSWD is the government agency tasked with protecting the welfare of children and families. They have the necessary authority and resources to investigate and intervene in cases of child abuse. Reporting to DSWD ensures that professional social workers and experts will step in to assess the situation, provide necessary interventions, and ensure the safety of the child. It is important to involve the appropriate authorities who are trained to handle cases of child abuse effectively. Reporting to the DSWD helps in safeguarding the well-being of the child and taking the necessary steps to address the situation appropriately.

Question 8 of 9

A postpartum client exhibits signs of mastitis, including breast tenderness, erythema, and warmth. Which nursing action is most appropriate?

Correct Answer: C

Rationale: Mastitis is an infection of the breast tissue that may occur in postpartum clients. When a postpartum client exhibits signs of mastitis, including breast tenderness, erythema, and warmth, it is crucial to notify the healthcare provider immediately. Prompt medical evaluation is necessary to determine the appropriate treatment plan, which may include antibiotics. Delay in treatment can lead to complications, such as abscess formation. Encouraging the client to continue breastfeeding and applying warm compresses may provide some relief but do not address the underlying infection. Administering oral antibiotics would require a prescription from the healthcare provider, hence notifying the provider is the most appropriate initial nursing action in this situation.

Question 9 of 9

The QA team has been bombarded by complaints of patients on their long waiting period in the OPD, before the health care professionals are examining them. In response to this concern, which type of quality assessment should the team implement?

Correct Answer: C

Rationale: Process evaluation focuses on assessing how well the activities and procedures are being conducted to achieve the desired outcomes. In this situation, the long waiting period in the OPD is a process issue related to the efficiency of patient flow and appointment scheduling practices. By implementing a process evaluation, the QA team can analyze and improve the workflow, identify bottlenecks causing delays, and streamline the processes to reduce waiting times for patients. This approach allows the team to make targeted improvements in the processes directly associated with the patient experience, leading to a more effective and efficient OPD operation.

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