Foundations and Adult Health Nursing Study Guide Answers

Correct Answer: C

Rationale: The pharmacist is legally responsible in this situation because they are the healthcare professional authorized to dispense medications according to the physician's order. In this case, the physician ordered a dose higher than the maximum safe dose recommended based on the infant's current weight. While the nurse administers the medication, the pharmacist has the responsibility to ensure that the correct dose is dispensed and to alert the physician if there is a discrepancy in the order. If the pharmacist dispensed the incorrect dose without verifying with the physician, they would bear legal responsibility for any adverse effects resulting from the medication error.

Correct Answer: B

Rationale: The symptoms of cyclic pelvic pain, dysmenorrhea (painful menstruation), dyspareunia (painful intercourse), and tender nodules along the uterosacral ligaments are classic findings associated with endometriosis. In endometriosis, tissue similar to the lining of the uterus (endometrium) grows outside the uterus, commonly on the ovaries, fallopian tubes, and pelvic peritoneum. The presence of tender nodules along the uterosacral ligaments is known as "nodularity" and is a characteristic feature of advanced endometriosis. It occurs due to the formation of endometrial implants that respond to hormonal changes during the menstrual cycle, resulting in inflammation, scarring, and pain in affected areas.

Correct Answer: A

Rationale: The presentation of a palpable, non-tender mass in the right neck, just below the angle of the mandible, along with ultrasound imaging findings of a well-defined, hypoechoic lesion with cystic components, is classic for a branchial cleft cyst. Branchial cleft cysts are congenital anomalies that arise from remnants of the branchial clefts or pouches during embryonic development. They are typically located along the anterior border of the sternocleidomastoid muscle, just below the mandible. Ultrasound imaging often shows a cystic lesion with well-defined borders and hypoechoic content, which is consistent with the described findings. Thyroglossal duct cysts usually present as midline neck masses that move with swallowing or tongue protrusion, not in the location described in the scenario. Lymphadenopathy would present as enlarged lymph nodes that may be tender and associated with systemic symptoms.

Correct Answer: B

Rationale: The cardiovascular disorder most likely responsible for the symptoms described is a pericardial effusion. A pericardial effusion is an accumulation of fluid within the pericardial space surrounding the heart. When a large pericardial effusion is present, it can lead to compression of the heart chambers, resulting in symptoms such as chest pain and dyspnea.

Correct Answer: A

Rationale: The most appropriate nursing diagnosis for this patient would be "Self-care deficit related to neuromuscular impairment." This diagnosis is supported by the information provided, which indicates that the patient is experiencing neuromuscular impairment that is likely affecting their ability to perform self-care activities. A self-care deficit diagnosis is relevant when a patient is unable to perform activities of daily living independently due to physical or cognitive limitations. In this case, the neuromuscular impairment is likely impacting the patient's ability to engage in self-care tasks, such as feeding, grooming, bathing, and dressing. By identifying and addressing this self-care deficit, the healthcare team can help the patient maintain optimal functioning and independence despite their neuromuscular impairment.