Answers and Rationale to Adult Health Questions

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The correct answer is:

✅ B. Place the patient on contact precautions

Purulent drainage (thick, yellow/green, foul-smelling discharge) is a sign of wound infection. The first priority is to prevent the spread of infection to others.

Contact precautions are immediately warranted to:

• Limit the spread of potentially infectious material
• Protect other patients and healthcare workers
• Follow infection control protocols
   

Initiating contact precautions includes:

• Wearing gloves and gown
• Using dedicated equipment (e.g., stethoscope, blood pressure cuff)
• Isolating the patient if necessary
   

• A. Contact the physician
  ➤ Important, but not the first step — containment of infection takes priority before provider notification.
• C. Irrigate the wound
  ➤ This is part of treatment, but infection control measures should come before wound care.
• D. Ask the patient to identify the level of pain on a numeric scale
  ➤ Pain assessment is important, but preventing transmission of infection is the more urgent priority.

The correct answer is:

✅ Partial thromboplastin time (PTT)
 

Heparin is an anticoagulant that works by inhibiting clotting factors, especially in the intrinsic and common pathways of the coagulation cascade.

To monitor the effectiveness and safety of heparin therapy, nurses and providers use:

• Activated Partial Thromboplastin Time (aPTT or PTT)
   

This test:

• Measures the time it takes for blood to clot
• Helps adjust heparin doses to maintain therapeutic levels
• Ensures the patient is not underdosed (risk of clotting) or overdosed (risk of bleeding)
   

• Prothrombin Time (PT)
  ➤ Used to monitor warfarin, not heparin.
• Bleeding Time
  ➤ Reflects platelet function, not heparin effectiveness.
• Protein Electrophoresis
  ➤ Used to assess types of proteins in the blood (e.g., in multiple myeloma), not coagulation status.

The correct answer is:

✅ B. They have less activity and decreased muscle tone

The primary reason elderly adults are more prone to constipation is due to:

• Decreased physical activity: Many older adults are less mobile, which slows down gastrointestinal (GI) motility.
• Reduced abdominal and pelvic muscle tone: This affects the ability to push stool effectively during defecation.

These factors slow peristalsis, leading to delayed transit time and harder stools.

• A. They eat a small volume of food with decreased bulk
  ➤ May contribute to constipation, but it's not the primary cause. Many older adults still eat adequate amounts.
   
• C. They have neurological changes in the GI tract
  ➤ Could occur in some disease states (like Parkinson’s or after a stroke), but not the main reason for constipation in the general elderly population.
   
• D. They have decreased sensation in the GI tract
  ➤ While decreased sensation may reduce the urge to defecate, it is not the primary factor.

Correct answer: C.

Rationale:

• This is a common complaint among older adults or clients with depression, chronic illness, or early signs of nutritional deficiencies.
• In an outpatient setting, decreased appetite is a frequent issue and something the nurse should expect and assess further.

• While this could indicate heat intolerance (possibly hyperthyroidism), it's less commonly volunteered compared to complaints about appetite loss.
• Also, heat intolerance isn't usually the most expected or routine observation in general outpatient assessments unless there's a specific endocrine concern.

• This would not be considered typical or concerning — it implies improvement, not a problem.

• This is unlikely unless there is a perception issue, and in aging adults, we typically see height loss, not gain.

Correct answer: A.

Rationale:

 This option is open-ended and encourages the client to describe their sleep patterns in their own words. It demonstrates therapeutic communication and allows the nurse to gather more detailed information before making assumptions or offering education or reassurance.

• Option B makes an assumption without first hearing from the client.
   
• Option C is dismissive and could minimize the client's concerns.
   
• Option D provides information but doesn't first assess the individual's specific situation.