Foundations and Adult Health Nursing Study Guide Answers

Correct Answer: D

Rationale: The appropriate nursing diagnosis for this situation is "Ineffective coping" because the patients with hypertension who stop taking their medications despite feeling good may be using this behavior as a maladaptive coping mechanism. It suggests that they might not fully understand the importance of medication adherence or are struggling to accept their diagnosis. By not adhering to their prescribed treatment, they are putting themselves at risk for complications associated with uncontrolled hypertension. Therefore, the nursing diagnosis of "Ineffective coping" addresses the patients' inability to deal with their condition in a healthy manner, leading to noncompliance with their treatment regimen.

Correct Answer: A

Rationale: An adequate contraction pattern during labor is characterized by regular contractions occurring at a frequency of three to 5 contractions in a 10-minute period, with resultant cervical dilatation. This pattern indicates efficient uterine activity that is helping to progress labor by dilating the cervix. In option A, the contractions are occurring at an appropriate frequency and are resulting in cervical dilatation, making it the correct choice for indicating an adequate contraction pattern.

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: D

Rationale: The nurse should prioritize positioning the patient in a left lateral decubitus position during gastric lavage to ensure procedural effectiveness. This position helps to promote optimal drainage of fluid and gastric contents. Placing the patient in a left lateral position allows gravity to assist in the passage of fluid and prevents the risk of aspiration. It also helps to minimize the risk of complications such as reflux of lavage fluid into the respiratory tract. Proper positioning is essential in enhancing the success of the gastric lavage procedure and promoting patient safety.

Correct Answer: B

Rationale: Records are IMPORTANT in health care as they serve as evidence of the health care services that have been provided to a patient. These records contain vital information such as the patient's medical history, diagnoses, treatments, medications, and test results. Keeping accurate and detailed records is crucial for monitoring a patient's progress, ensuring appropriate care is being provided, and serving as a reference point for healthcare providers involved in the patient's treatment. Additionally, health care records are essential for legal and insurance purposes, quality assessment, research, and continuity of care.