Foundations and Adult Health Nursing Study Guide Answers

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A woman in active labor is diagnosed with uterine rupture. What is the priority nursing action?

  • A. Preparing for immediate cesarean section
  • B. Administering intravenous oxytocin to augment contractions
  • C. Assisting the mother into a hands-and-knees position
  • D. Initiating cardiopulmonary resuscitation (CPR)
Correct Answer: A

Rationale: The priority nursing action for a woman diagnosed with uterine rupture during labor is to prepare for immediate cesarean section. Uterine rupture is a serious obstetric emergency that can lead to severe maternal and fetal complications, including hemorrhage, fetal distress, and injury to both mother and baby. A cesarean section is necessary to deliver the baby promptly and address any potential complications, such as controlling bleeding and ensuring the safety of both the mother and the baby. Time is critical in these situations, and prompt surgical intervention is essential to optimize outcomes. Administering intravenous oxytocin or assisting the mother into a hands-and-knees position would not address the immediate risks associated with uterine rupture. Initiating cardiopulmonary resuscitation (CPR) is only necessary if the mother's condition deteriorates to the point of cardiac or respiratory arrest, which may occur as a result of significant hemorrhage or other complications associated with uterine

You may also like to solve these questions

What should be the INITIAL S'TEP in the process of change for the senior nurse

  • A. set goals and priorities regarding the change process.
  • B. Plan strategies to implement the change.
  • C. Identify potential solutions and strategies for the change.
  • D. Identify the inefficiency that needs improvement or correction
Correct Answer: D

Rationale: The initial step in the process of change for the senior nurse should be to identify the inefficiency that needs improvement or correction. Before setting goals, planning strategies, or identifying solutions, it is essential to first pinpoint the specific area or aspect that requires change. By identifying the inefficiency, the senior nurse can gain a clear understanding of the root cause of the issue and focus efforts on addressing it effectively. This step lays the foundation for the rest of the change process by providing a specific target for improvement.

Before finishing the check up, which of the following principles is NOT included among the principles of guidance in handling Richard?

  • A. Controlling temper tantrums
  • B. Basing her expectations within the child's limitations.
  • C. Acceptance of masturbation as a normal phenomenon to be discouraged in public.
  • D. Reinforcing the correct use of language.
Correct Answer: D

Rationale: The principles of guidance in handling Richard involve understanding and addressing the behaviors and needs of the child, such as controlling temper tantrums, basing expectations within the child's limitations, and acceptance of certain behaviors like masturbation as normal but to be discouraged in public. However, reinforcing the correct use of language is not typically included as a principle specifically in handling Richard. Therefore, this choice is NOT included among the principles of guidance in this context.

A patient presents with sudden-onset weakness and sensory loss on one side of the body, along with difficulty speaking and understanding speech. Symptoms began approximately 1 hour ago and have partially resolved since then. Which of the following neurological conditions is most likely responsible for these symptoms?

  • A. Ischemic stroke
  • B. Transient ischemic attack (TIA)
  • C. Hemorrhagic stroke
  • D. Subarachnoid hemorrhage
Correct Answer: B

Rationale: The patient's presentation of sudden-onset weakness and sensory loss on one side of the body, along with difficulty speaking and understanding speech that partially resolved within one hour, is consistent with a transient ischemic attack (TIA). TIAs are caused by temporary disruption of blood flow to a part of the brain, leading to transient neurological symptoms. Unlike an ischemic stroke, which results in permanent damage to brain tissue due to prolonged interruption of blood flow, TIAs are transient and resolve within 24 hours. Hemorrhagic strokes and subarachnoid hemorrhages typically present with sudden, severe headaches, and may not improve or resolve quickly as seen in this case.

You encounter a conscious adult choking on a piece of food. The person is coughing forcefully but unable to speak or breathe effectively. What is the most appropriate action?

  • A. Encourage continued coughing.
  • B. Perform abdominal thrusts (Heimlich maneuver).
  • C. Deliver back blows.
  • D. Administer rescue breaths.
Correct Answer: B

Rationale: The most appropriate action in this situation is to perform abdominal thrusts, also known as the Heimlich maneuver. This technique is used to clear a blocked airway caused by a choking obstruction. Encouraging continued coughing may not be effective if the person is unable to dislodge the obstruction on their own. Delivering back blows can sometimes be effective, but abdominal thrusts are more commonly recommended in cases of choking in adults. Administering rescue breaths is not recommended if the person is conscious and able to cough, as it may worsen the situation by pushing the obstruction further down. By quickly performing abdominal thrusts, you can help dislodge the obstruction and potentially save the person's life.

A patient is prescribed a beta-adrenergic agonist for the management of asthma. Which adverse effect should the nurse monitor closely in the patient?

  • A. Hypotension
  • B. Hyperkalemia
  • C. Tachycardia
  • D. Hypoglycemia
Correct Answer: C

Rationale: Beta-adrenergic agonists stimulate beta-adrenergic receptors in the heart, leading to an increase in heart rate (tachycardia). This is a common adverse effect associated with the use of beta-adrenergic agonists in the management of conditions such as asthma. Monitoring for tachycardia is important because it can potentially lead to other complications such as palpitations, arrhythmias, and exacerbation of underlying cardiovascular conditions. It is essential for the nurse to closely monitor the patient for any signs or symptoms of tachycardia and report any abnormalities to the healthcare provider promptly to ensure appropriate management and prevent further complications.

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