Foundations and Adult Health Nursing Study Guide Answers

Correct Answer: A

Rationale: The presentation of a palpable, non-tender mass in the right neck, just below the angle of the mandible, along with ultrasound imaging findings of a well-defined, hypoechoic lesion with cystic components, is classic for a branchial cleft cyst. Branchial cleft cysts are congenital anomalies that arise from remnants of the branchial clefts or pouches during embryonic development. They are typically located along the anterior border of the sternocleidomastoid muscle, just below the mandible. Ultrasound imaging often shows a cystic lesion with well-defined borders and hypoechoic content, which is consistent with the described findings. Thyroglossal duct cysts usually present as midline neck masses that move with swallowing or tongue protrusion, not in the location described in the scenario. Lymphadenopathy would present as enlarged lymph nodes that may be tender and associated with systemic symptoms.

Correct Answer: B

Rationale: When Nurse Sarah distributed a Patient satisfaction survey form to be filled by the consumer upon discharge in a hospital setting, it aligns with the quality standard of identifying Patient rights and welfare. Patient satisfaction surveys aim to gather feedback from patients about their experiences with the health care services provided. By distributing such surveys, the hospital is demonstrating its commitment to ensuring the rights and welfare of patients by seeking their feedback, understanding their concerns, and incorporating their suggestions for improvement. This initiative helps in enhancing the quality of care provided to patients and ultimately contributes to improving overall patient outcomes and satisfaction.

Correct Answer: C

Rationale: In cases of persistent fetal malpresentation, such as a transverse lie position, a cesarean section is often the safest and most effective intervention to address the abnormal labor presentation. Delivering a baby in a transverse lie position vaginally is associated with high risks, including fetal complications such as umbilical cord prolapse and head entrapment. Therefore, to ensure the safety of both the mother and the baby, a cesarean section is usually the most appropriate and timely intervention to address this situation. It is crucial to prioritize the immediate preparation and facilitation of a cesarean section in cases of persistent fetal malpresentation to prevent potential complications and ensure the best outcome for the mother and the baby.

Correct Answer: C

Rationale: The most appropriate nursing action in this scenario is to notify the healthcare provider immediately. The client's presentation of calf pain, swelling, and warmth could be indicative of a deep vein thrombosis (DVT), which is a serious condition that requires prompt evaluation and intervention by the healthcare provider. DVT is a blood clot that forms in a deep vein, often in the leg, and if left untreated, it can lead to life-threatening complications such as pulmonary embolism. Therefore, timely communication with the healthcare provider is critical to ensure that the client receives the appropriate diagnostic testing and treatment to address the potential DVT. Applying warm compresses, encouraging ambulation, or administering NSAIDs would not be the first-line interventions for a suspected DVT and may even worsen the condition.

Correct Answer: B

Rationale: Long-term aspirin therapy, especially at higher doses, can increase the risk of gastrointestinal bleeding. Aspirin irreversibly inhibits cyclooxygenase enzyme, which is essential for the production of prostaglandins involved in mucosal protection of the gastrointestinal tract. Without these protective prostaglandins, the stomach lining becomes more susceptible to damage from gastric acid, leading to potential ulcer formation and bleeding. Patients with a history of coronary artery disease may be on aspirin for secondary prevention, and it is crucial to monitor for signs of bleeding such as black, tarry stools or abdominal pain. The benefits of aspirin in preventing cardiovascular events need to be weighed against the risk of adverse effects like gastrointestinal bleeding, especially in patients on long-term therapy.