Adult Health Nursing Flashcards

A patient with a new colostomy expresses disgust and refuses to look at the stoma. Which nursing response is most therapeutic?

Answer: Acknowledge the patient's feelings and gradually involve them in ostomy care

Altered body image is a major psychosocial concern after ostomy formation. Therapeutic nursing involves acknowledging feelings as valid, normalizing the emotional response, and gradually building the patient's confidence and self-efficacy in self-care.

What is the most important nursing consideration when administering potassium chloride IV?

Answer: Never give undiluted IV push; always dilute and administer slowly

IV potassium must always be diluted (maximum 10 mEq/hr peripherally, 20 mEq/hr centrally) and never given as an IV push. Rapid potassium administration causes fatal cardiac dysrhythmias.

A patient with peripheral arterial disease reports leg pain that worsens with walking and improves with rest. This is called:

Answer: Intermittent claudication

Intermittent claudication is the hallmark symptom of peripheral arterial disease — cramping or aching pain in the legs during walking (exercise increases oxygen demand beyond supply) that reliably resolves with rest (decreased demand).

Which finding should the nurse report immediately in a patient who had a carotid endarterectomy?

Answer: Sudden neck swelling and difficulty breathing

After carotid endarterectomy, neck hematoma can rapidly compress the airway, causing life-threatening airway obstruction. Sudden swelling with stridor or dyspnea is a surgical emergency requiring immediate intervention.

A patient has been prescribed ACE inhibitors for hypertension. What side effect should the nurse teach the patient to expect?

Answer: A persistent dry cough

ACE inhibitors (e.g., enalapril, lisinopril) block bradykinin breakdown, causing bradykinin accumulation in the lungs. This produces a persistent dry, non-productive cough in 10–20% of patients, which is the most common reason for switching to an ARB.

What is the normal range for adult serum sodium?

Answer: 135–145 mEq/L

Normal serum sodium is 135–145 mEq/L. Hyponatremia (145) causes cellular dehydration and neurological dysfunction from brain cell shrinkage.