Foundations and Adult Health Nursing Study Guide Answers

Correct Answer: B

Rationale: Antipsychotic medications can cause metabolic side effects, including hyperglycemia (high blood sugar). Patients with bipolar disorder who are prescribed antipsychotic medications are at risk for developing new-onset diabetes or exacerbating preexisting diabetes. Monitoring blood glucose levels is essential to detect hyperglycemia early and prevent complications such as diabetic ketoacidosis. While hypertension, hypotension, and hypernatremia are possible side effects of certain medications, they are not typically associated with antipsychotic medications commonly used in the management of bipolar disorder. Hyperglycemia is a serious concern in this population due to the risk of developing diabetes or worsening of existing diabetes.

Correct Answer: D

Rationale: The appropriate nursing diagnosis for this situation is "Ineffective coping" because the patients with hypertension who stop taking their medications despite feeling good may be using this behavior as a maladaptive coping mechanism. It suggests that they might not fully understand the importance of medication adherence or are struggling to accept their diagnosis. By not adhering to their prescribed treatment, they are putting themselves at risk for complications associated with uncontrolled hypertension. Therefore, the nursing diagnosis of "Ineffective coping" addresses the patients' inability to deal with their condition in a healthy manner, leading to noncompliance with their treatment regimen.

Correct Answer: C

Rationale: The correct action for the nurse to take when observing signs of distress and discomfort in a patient during assessment is to offer emotional support and actively listen to the patient's concerns. Ignoring the patient's distress may lead to worsening of the patient's condition and can be detrimental to the patient's well-being. Documenting the findings and informing the healthcare provider later is important but should not be the immediate response when a patient is in distress. Administering pain medication without further assessment is also not appropriate as the nurse needs to understand the underlying cause of the distress before providing appropriate interventions. Offering emotional support and actively listening to the patient's concerns can help the nurse understand the patient's needs, provide comfort, and potentially address the root cause of the distress.

Correct Answer: A

Rationale: An adequate contraction pattern during labor is characterized by regular contractions occurring at a frequency of three to 5 contractions in a 10-minute period, with resultant cervical dilatation. This pattern indicates efficient uterine activity that is helping to progress labor by dilating the cervix. In option A, the contractions are occurring at an appropriate frequency and are resulting in cervical dilatation, making it the correct choice for indicating an adequate contraction pattern.

Correct Answer: B

Rationale: When communicating with a patient experiencing delirium, the nurse's priority is to provide clear and simple explanations to minimize confusion. Delirium can cause disorientation, confusion, and impaired cognitive function, making it difficult for the patient to understand complex information. Using simple language and clear explanations can help the patient better comprehend the situation and reduce anxiety. It is essential for the nurse to speak calmly, use reassuring gestures, and maintain a supportive presence to effectively communicate with a delirious patient. This approach can help establish a sense of trust and foster a therapeutic nurse-patient relationship during the challenging experience of delirium.