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: D

Rationale: An advance directive is a legal document that specifies a person's healthcare preferences and instructions for medical treatment in the event they are unable to communicate their wishes. It typically includes decisions about life-sustaining treatments, resuscitation, and end-of-life care. In the scenario provided, the document provided by the patient to the nurse outlining his healthcare team's instructions postoperatively indicates that he has an advance directive in place to guide his medical care if necessary. In contrast, informed consent is a process in which a patient gives permission for medical treatment after being informed about the risks, benefits, and alternatives. Patient's Bill of Rights outlines the patient's rights within the healthcare system, and an insurance card provides information about the patient's insurance coverage.

Correct Answer: B

Rationale: The patient's presentation of sudden-onset weakness and sensory loss on one side of the body, along with difficulty speaking and understanding speech that partially resolved within one hour, is consistent with a transient ischemic attack (TIA). TIAs are caused by temporary disruption of blood flow to a part of the brain, leading to transient neurological symptoms. Unlike an ischemic stroke, which results in permanent damage to brain tissue due to prolonged interruption of blood flow, TIAs are transient and resolve within 24 hours. Hemorrhagic strokes and subarachnoid hemorrhages typically present with sudden, severe headaches, and may not improve or resolve quickly as seen in this case.

Correct Answer: B

Rationale: The presentation of knee pain and swelling following a fall onto a flexed knee, along with a palpable effusion and tenderness along the joint line, is highly suggestive of a meniscus injury. The McMurray's test specifically evaluates for meniscal tears. In this case, the presence of pain and clicking with passive knee flexion and internal rotation indicates a medial meniscus tear as the most likely diagnosis. Patellar tendinitis usually presents with anterior knee pain that is worsened by activities such as jumping or running. Lateral collateral ligament (LCL) sprain typically presents with lateral knee pain and instability. Quadriceps tendon rupture would present with significant weakness and inability to fully extend the knee, which is not described in this scenario.

Correct Answer: B

Rationale: Phlebitis is the most common complication that patients may contract while on IV therapy. Phlebitis is the inflammation of the vein where the IV is inserted, which can cause redness, pain, and swelling along the vein. It can be caused by mechanical irritation, chemical irritation, or infection from the IV catheter. Prompt removal of the IV catheter and appropriate treatment are necessary to manage phlebitis and prevent further complications. While embolism, cardiac overload, and aneurysm are potential complications of IV therapy, phlebitis is more commonly seen in clinical practice.