Foundations and Adult Health Nursing Study Guide Answers

Correct Answer: A

Rationale: Illiterate clients may have difficulty understanding spoken or written information. Using symbols and images can help convey important messages and instructions in a visual way that can be easily understood without relying on literacy skills. This communication intervention is effective in ensuring that the client understands the information being provided, promoting better adherence to treatment plans and overall health outcomes.

Correct Answer: A

Rationale: An open chest wound, also known as a sucking chest wound, can lead to a collapsed lung and respiratory distress. Immediate management involves sealing the wound to prevent air from entering the pleural space and further compromising the patient's respiratory function. Applying a sterile dressing over the wound helps to prevent contamination and occluding the wound with an airtight covering, such as an occlusive dressing, can effectively reduce the risk of a tension pneumothorax, a serious complication that can arise from a sucking chest wound. These interventions help to stabilize the patient's condition and improve the chances of a successful recovery. Administering supplemental oxygen, though beneficial, would be secondary to the primary management of sealing the chest wound. Providing emotional support is important but addressing the physical emergency takes precedence. Elevating the patient's legs would not be appropriate in managing an open chest wound.

Correct Answer: A

Rationale: The client is exhibiting signs and symptoms of respiratory alkalosis. When a person is experiencing respiratory alkalosis, there is an excessive loss of carbon dioxide (CO2) from the body, leading to elevated blood pH. The marked increase in the rate and depth of respirations as well as symptoms of anxiety, restlessness, and irritability are characteristic of respiratory alkalosis. This condition can be caused by hyperventilation, anxiety, or fever, which result in excessive elimination of CO2 from the body, leading to an imbalance in the acid-base status. Treatment for respiratory alkalosis involves addressing the underlying cause, such as providing reassurance to decrease anxiety or managing the breathing pattern to normalize CO2 levels.

Correct Answer: A

Rationale: The step of the nursing process that identifies the family's health-seeking behavior is Assessment. During the assessment phase, the nurse gathers information about the family's health practices, beliefs, priorities, and past experiences related to seeking healthcare. This helps the nurse understand how the family approaches health and healthcare, which is crucial for providing tailored and effective care. By assessing the family's health-seeking behavior, the nurse can better collaborate with them to address their health needs and promote positive health outcomes.

Correct Answer: A

Rationale: The priority nursing action for a woman diagnosed with uterine rupture during labor is to prepare for immediate cesarean section. Uterine rupture is a serious obstetric emergency that can lead to severe maternal and fetal complications, including hemorrhage, fetal distress, and injury to both mother and baby. A cesarean section is necessary to deliver the baby promptly and address any potential complications, such as controlling bleeding and ensuring the safety of both the mother and the baby. Time is critical in these situations, and prompt surgical intervention is essential to optimize outcomes. Administering intravenous oxytocin or assisting the mother into a hands-and-knees position would not address the immediate risks associated with uterine rupture. Initiating cardiopulmonary resuscitation (CPR) is only necessary if the mother's condition deteriorates to the point of cardiac or respiratory arrest, which may occur as a result of significant hemorrhage or other complications associated with uterine