Foundations and Adult Health Nursing Study Guide Answers

Correct Answer: B

Rationale: The scenario described in the question is most indicative of endometriosis. Endometriosis is a gynecological condition in which tissue similar to the lining of the uterus grows outside of the uterus. Classic symptoms of endometriosis include cyclic pelvic pain, dysmenorrhea (painful periods), and infertility. The presence of a "chocolate cyst" (also known as an endometrioma) within the ovary on pelvic ultrasound is a characteristic finding in endometriosis. These cysts are filled with old blood, giving them a dark, chocolate-like appearance on imaging. Polycystic ovary syndrome (PCOS) typically presents with irregular periods, signs of hyperandrogenism, and multiple small follicles on ultrasound. Ovarian torsion and ovarian cyst rupture would present with acute-onset symptoms and may not necessarily be associated with cyclic pelvic pain and dysmenorrhea as described in the

Correct Answer: C

Rationale: Hyperthyroidism is a condition where the thyroid gland produces an excess amount of thyroid hormone. One of the clinical manifestations of hyperthyroidism is a fine motor tremor, which is characterized by hand tremors or shaky movements in the fingers. This tremor is often more noticeable when the individual is trying to perform delicate tasks requiring fine motor skills. It is important for Nurse Rachel to watch for this symptom in patient Claire as it can impact her ability to perform daily activities and may require intervention or management strategies to help alleviate the tremor and improve quality of life.

Correct Answer: C

Rationale: Intracerebral hemorrhage occurs when there is bleeding directly into the brain tissue, often due to conditions such as hypertension or vascular malformations. The sudden-onset severe headache, altered mental status, and focal neurological deficits described in the patient are typical symptoms of an intracerebral hemorrhage. The location of the hemorrhagic lesion within the right basal ganglia corresponds to the clinical presentation. Ischemic stroke, subarachnoid hemorrhage, and transient ischemic attack (TIA) typically have different presentations and imaging findings compared to an intracerebral hemorrhage. Therefore, in this scenario, intracerebral hemorrhage is the most likely cause of the patient's symptoms.

Correct Answer: B

Rationale: CPAP therapy is considered the gold standard treatment for obstructive sleep apnea (OSA) and is the most appropriate intervention for managing OSA and improving symptoms. CPAP therapy involves using a machine that delivers a continuous flow of air through a mask worn over the nose or mouth during sleep. This air pressure helps keep the airway open, preventing the collapse that causes apneas and snoring during sleep.

Correct Answer: A

Rationale: The most appropriate nursing diagnosis for this patient would be "Self-care deficit related to neuromuscular impairment." This diagnosis is supported by the information provided, which indicates that the patient is experiencing neuromuscular impairment that is likely affecting their ability to perform self-care activities. A self-care deficit diagnosis is relevant when a patient is unable to perform activities of daily living independently due to physical or cognitive limitations. In this case, the neuromuscular impairment is likely impacting the patient's ability to engage in self-care tasks, such as feeding, grooming, bathing, and dressing. By identifying and addressing this self-care deficit, the healthcare team can help the patient maintain optimal functioning and independence despite their neuromuscular impairment.