Foundations and Adult Health Nursing Study Guide Answers

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: A

Rationale: The primary responsibility for obtaining informed consent lies with the surgeon who will be performing the procedure. Informed consent is a process where the healthcare provider explains the procedure, benefits, risks, and alternatives to the patient, allowing them to make an informed decision about their care. While other healthcare team members may also participate in this process, the ultimate responsibility typically rests with the surgeon as they are the one performing the surgery.

Correct Answer: A

Rationale: Precipitous labor is completed in less than 3 hours from the onset of labor to delivery. It is characterized by rapid labor progression, with contractions quickly increasing in intensity and frequency. This can pose risks for both the mother and baby, such as increased risk of maternal lacerations, fetal distress, and postpartum hemorrhage. It is important for healthcare providers to be prepared for rapid delivery in cases of precipitous labor.

Correct Answer: C

Rationale: The nurse should obtain interpreter services or language assistance as needed to ensure effective communication with a patient who has limited English proficiency. Using an interpreter will facilitate clear and accurate communication between the nurse and the patient, enabling the patient to fully understand their care, treatment, and any instructions provided. Speaking loudly or slowly, using medical jargon, or ignoring the language barriers are not effective strategies for communicating with a patient who has limited English proficiency. Utilizing interpreter services demonstrates respect for the patient's language and cultural needs, which is essential for providing high-quality care.

Correct Answer: B

Rationale: Ramsay Hunt syndrome is caused by the varicella-zoster virus affecting the geniculate ganglion, leading to a triad of symptoms known as the Hunt syndrome: facial paralysis, ear pain, and a vesicular rash in the ear or palate. The facial paralysis in Ramsay Hunt syndrome is usually peripheral, similar to Bell's palsy, but may be more severe. In addition to facial paralysis, the patient may have the inability to close the eye on the affected side (lagophthalmos) and loss of taste sensation on the anterior two-thirds of the tongue due to involvement of the chorda tympani nerve. This differentiation is important to consider in the context of our patient's presentation.