Foundations and Adult Health Nursing Test Bank

Correct Answer: A

Rationale: Assisting the mother into a hands-and-knees position should be prioritized to facilitate fetal rotation and optimize labor progress in the case of persistent occiput posterior fetal position. This position helps in promoting fetal rotation to a more favorable position for delivery by allowing the baby's head to move into the anterior position. It can help alleviate back pain and may help reduce the duration of labor. This simple maneuver can sometimes correct the malposition without the need for interventions like instrumental delivery. It is a non-invasive and effective technique that can be easily implemented by healthcare providers to support the progression of labor.

Correct Answer: B

Rationale: Identifying the patient's stage of change is crucial when someone expresses a desire to be "detoxified" from a substance like marijuana. The Transtheoretical Model (Stages of Change) outlines different stages individuals go through when making behavior changes. By identifying which stage the patient is in (precontemplation, contemplation, preparation, action, maintenance, or relapse), the nurse can tailor interventions and support accordingly. This approach helps ensure that interventions are effective and appropriate for the individual's readiness for change. It is important to meet the patient where they are in their journey towards detoxification and offer support and guidance accordingly.

Correct Answer: B

Rationale: Spondylosis is a condition characterized by degenerative changes in the intervertebral discs, leading to narrowing of the disc space and the formation of osteophytes (bone spurs). This degenerative process commonly occurs with aging and can cause symptoms such as neck or back pain, stiffness, and reduced range of motion. Spondylosis is a common finding on imaging studies like X-rays and MRI scans in individuals over the age of 50 and is a natural part of the aging process of the spine.

Correct Answer: B

Rationale: Acute otitis media is the most likely condition responsible for this presentation. The sudden onset of severe, unilateral ear pain, diminished hearing, and purulent otorrhea are classic symptoms of acute otitis media. Otoscopic examination revealing a bulging, erythematous tympanic membrane with obscured landmarks further supports the diagnosis. The bulging of the tympanic membrane is due to the accumulation of fluid and pus behind it, causing the characteristic appearance. Treatment typically involves antibiotics to help clear the infection and relieve symptoms. If left untreated, acute otitis media can lead to complications such as perforation of the eardrum or mastoiditis.

Correct Answer: A

Rationale: In a patient with acute myocardial infarction (MI) presenting with ST-segment elevation on ECG, the healthcare team should prioritize performing emergent coronary angiography for revascularization. This intervention, also known as primary percutaneous coronary intervention (PCI), involves opening up the blocked coronary artery responsible for the MI. Timely reperfusion of the affected artery is crucial in reducing myocardial damage and improving outcomes in acute MI patients. PCI is considered the preferred method for revascularization in patients with ST-segment elevation MI, as it has been shown to be more effective and associated with better outcomes compared to fibrinolytic therapy.