Foundations and Adult Health Nursing Study Guide Answers

Correct Answer: B

Rationale: Maternal anxiety can contribute to a prolonged latent phase during labor. Stress and anxiety can trigger the release of stress hormones such as adrenaline, which can interfere with the production of oxytocin, the hormone responsible for initiating contractions. This can result in irregular and ineffective contractions, leading to a prolonged latent phase. It is important for the nurse to assess the woman's anxiety levels and provide reassurance and support to help facilitate the progression of labor.

Correct Answer: A

Rationale: Somatic hypermutation is the mechanism responsible for generating diversity in the antigen-binding sites of immunoglobulins. During somatic hypermutation, point mutations are introduced into the variable regions of immunoglobulin genes in B cells. These mutations occur randomly and lead to a wide range of amino acid changes in the antigen-binding sites of antibodies. As a result, a diverse repertoire of antibodies with varying specificities for different antigens is created. Gene rearrangement and isotype switching are other mechanisms that contribute to antibody diversity but do not specifically target the antigen-binding sites. Clonal expansion, on the other hand, refers to the proliferation of specific B cell clones after activation by antigens, which amplifies the immune response but does not directly impact the diversity of antigen-binding sites.

Correct Answer: A

Rationale: The clinical presentation of fatigue, pallor, exertional dyspnea along with the laboratory findings of severe anemia, low serum iron, low transferrin saturation, and elevated TIBC are consistent with iron deficiency anemia. In iron deficiency anemia, there is inadequate iron available for erythropoiesis leading to microcytic hypochromic anemia. The low serum iron and transferrin saturation, along with the elevated TIBC, indicate decreased iron stores and increased iron-binding capacity as the body tries to compensate for the deficiency by increasing absorption and recycling of iron. Anemia of chronic disease typically presents with mild to moderate anemia, normal to low TIBC, and low transferrin saturation due to iron sequestration in macrophages. Sideroblastic anemia usually has elevated serum iron, high saturation, and normal to low TIBC. Thalassemia presents with microcytic hyp

Correct Answer: C

Rationale: Type 2 diabetes mellitus is characterized by insulin resistance in the peripheral tissues and defective beta cell secretion with loss of insulin. In type 2 diabetes, there is typically not destruction of beta cells from an autoimmune mechanism that leads to lack of insulin and hyperglycemia as seen in type 1 diabetes mellitus. Instead, in type 2 diabetes, the pancreas initially produces insulin, but the body's cells become resistant to its effects. This results in hyperglycemia due to the inability of the body to properly regulate blood sugar levels. Therefore, choice C is not true for type 2 diabetes mellitus.

Correct Answer: A

Rationale: Patients with COPD are at increased risk for developing ventilator-induced lung injury (VILI) due to their underlying lung pathology. Using a low tidal volume strategy (6-8 ml/kg predicted body weight) has been shown to reduce the risk of VILI in these patients. Additionally, applying high positive end-expiratory pressure (PEEP) helps to recruit collapsed alveoli, improve oxygenation, and decrease the risk of barotrauma by keeping the alveoli open throughout the respiratory cycle. Therefore, the most appropriate ventilator settings to minimize the risk of VILI in a COPD patient with acute exacerbation and respiratory failure requiring mechanical ventilation would be low tidal volume and high PEEP.