Foundations and Adult Health Nursing Study Guide Answers

Correct Answer: B

Rationale: In the scenario of a woman in active labor experiencing a prolonged second stage with inadequate expulsive efforts, the appropriate nursing intervention to facilitate fetal descent would be to apply fundal pressure. Fundal pressure, or applying pressure on the upper abdomen just above the uterine fundus, can help in directing the fetal head downwards and aiding in the descent through the birth canal. It is important to note that fundal pressure should be applied carefully and with proper technique to prevent excessive force that could potentially harm the mother or the baby. Encouraging the mother to push forcefully during contractions can be helpful, but the addition of fundal pressure can provide extra assistance in cases of inadequate progress. Immediate cesarean section may be considered if other interventions are unsuccessful or if there are concerns for fetal distress. Administering intravenous magnesium sulfate for uterine relaxation is not indicated in this situation.

Correct Answer: A

Rationale: The most appropriate intervention for managing ventilator-associated pneumonia (VAP) caused by multidrug-resistant organisms (MDROs) is to administer combination antibiotic therapy targeting the specific resistant pathogens identified in the patient's culture results. MDROs are often resistant to multiple antibiotics, so combination therapy is required to maximize the chances of effectively treating the infection. Identifying the specific pathogens causing the VAP through cultures is crucial in tailoring the antibiotic therapy to target these organisms effectively. Implementing appropriate antibiotic therapy promptly is essential to improve outcomes and prevent further complications in patients with VAP caused by MDROs. Option A is the priority intervention in this case to address the multidrug-resistant nature of the infection and provide targeted treatment for the patient.

Correct Answer: D

Rationale: Follicular thyroid carcinoma is a type of thyroid cancer that arises from the follicular cells of the thyroid gland. Patients with follicular thyroid carcinoma may present with a palpable thyroid nodule, which in this case is causing signs of hyperthyroidism due to the overproduction of thyroid hormones by the malignant cells. Fine-needle aspiration biopsy revealing follicular cells with nuclear features suggestive of malignancy further supports the diagnosis of follicular thyroid carcinoma in this scenario.

Correct Answer: A

Rationale: A district hospital is an example of a secondary health facility. Secondary health facilities are the intermediate level of healthcare services, providing a higher level of care compared to primary health facilities like rural health units and barangay health stations. District hospitals typically offer more specialized medical services, diagnostic facilities, and inpatient care that are not available at lower-level health facilities. When Nurse Vince refers a patient to a district hospital, it means that the patient requires more extensive and specialized medical care beyond what can be provided at the primary level of care.

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.