Foundations and Adult Health Nursing Study Guide Answers

Correct Answer: C

Rationale: The nurse should ask the mother information related to their daughter's menarche. Menarche refers to the first occurrence of menstruation in a girl, which is an important milestone in her development. By inquiring about the daughter's menarche, the nurse can gather essential information about the daughter's reproductive health, growth, and development. This allows the nurse to assess whether the daughter's menstrual cycle is regular and if there are any concerns related to her reproductive health. Understanding the daughter's menarche history is vital in providing appropriate healthcare and support for her.

Correct Answer: B

Rationale: The epigastrium is the upper middle region of the abdomen, lying above the umbilical region and between the hypochondriac regions. It contains several organs including the duodenum, pancreas, portion of the liver, and the pyloric end of the stomach. The duodenum is the first part of the small intestine, the pancreas is a crucial organ for digestion and hormone regulation, the liver aids in digestion and detoxification, and the pyloric end of the stomach connects the stomach to the small intestine for further digestion and absorption of nutrients. These organs are typically assessed and examined when focusing on the epigastrium during a physical examination.

Correct Answer: B

Rationale: Streptococcus pneumoniae is the most common causative organism of bacterial pneumonia in adults. It is responsible for the majority of community-acquired pneumonia cases. Streptococcus pneumoniae is a gram-positive bacteria and is known to cause typical pneumonia characterized by sudden onset of high fever, productive cough with blood-tinged or rust-colored sputum, chest pain, and consolidation on chest imaging. Other organisms like Legionella pneumophila (choice A), Mycoplasma pneumoniae (choice C), and Haemophilus influenzae (choice D) can also cause pneumonia, but Streptococcus pneumoniae is the most likely culprit based on the patient's test results.

Correct Answer: C

Rationale: Mast cells are primarily responsible for mediating allergic responses such as severe allergies. When an allergen triggers the immune response, mast cells release histamine, leukotrienes, and other inflammatory mediators. These substances cause symptoms such as difficulty breathing, hives, and swelling. Basophils also release histamine, but mast cells are more abundant in tissues and play a significant role in allergic reactions. Eosinophils are involved in allergic reactions but are more focused on combating parasitic infections. Neutrophils are not typically involved in allergic responses but play a key role in combating bacterial infections.

Correct Answer: C

Rationale: The priority nursing intervention to promote optimal wound healing in a client who had an episiotomy is providing perineal care using peri-bottles with warm water. Warm water helps to cleanse the area, reduce the risk of infection, and promote circulation, which aids in wound healing. Peri-bottles are especially gentle and effective in cleaning the perineal area without causing trauma to the incision site. Encouraging frequent perineal hygiene with soap and water may be too harsh on the incision site and could lead to irritation. Applying antibiotic ointment after each void is not necessary unless prescribed by the healthcare provider, as overuse of antibiotics can lead to resistance. Instructing the client on proper peri-pad application is important for comfort and cleanliness but is not as crucial as gentle perineal care using peri-bottles with warm water for promoting optimal wound healing.