Foundations and Adult Health Nursing Study Guide Answers

Correct Answer: D

Rationale: The principles of guidance in handling Richard involve understanding and addressing the behaviors and needs of the child, such as controlling temper tantrums, basing expectations within the child's limitations, and acceptance of certain behaviors like masturbation as normal but to be discouraged in public. However, reinforcing the correct use of language is not typically included as a principle specifically in handling Richard. Therefore, this choice is NOT included among the principles of guidance in this context.

Correct Answer: C

Rationale: The esophagus is responsible for propelling food from the oral cavity to the stomach through a series of coordinated muscular contractions. These contractions are known as peristalsis. The esophagus is a muscular tube connecting the throat (pharynx) to the stomach and plays a crucial role in moving food bolus from the mouth to the stomach for digestion. The tongue helps in the chewing and swallowing of food, the pharynx is involved in the passage of food and air, and the epiglottis helps prevent food from entering the airways during swallowing. However, it is the esophagus that actively moves the food to the stomach.

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.

Correct Answer: A

Rationale: The nurse should monitor serum potassium levels closely during ACE inhibitor therapy because ACE inhibitors can lead to an increase in serum potassium levels, known as hyperkalemia. ACE inhibitors block the conversion of angiotensin I to angiotensin II, which in turn decreases aldosterone secretion. Aldosterone normally acts in the kidneys to reabsorb sodium and water and excrete potassium. Therefore, when aldosterone secretion is decreased due to ACE inhibitor therapy, there can be an increase in potassium retention, potentially leading to hyperkalemia. Monitoring serum potassium levels is essential to prevent complications associated with hyperkalemia, such as cardiac arrhythmias.

Correct Answer: C

Rationale: Placenta previa is a condition where the placenta partially or completely covers the cervix, leading to painless vaginal bleeding during pregnancy. In the scenario described, the painless, bright red vaginal bleeding at 34 weeks gestation with a closed cervix is classic for placenta previa. This condition is more common in the third trimester and can be diagnosed through ultrasound. It is important to manage placenta previa carefully to prevent complications such as severe bleeding, preterm birth, and maternal/fetal distress.