Foundations and Adult Health Nursing Study Guide Answers

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: 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: The correct way to apply anti-scabies lotion is to cover all skin areas, not just the affected areas or red areas. Scabies is a contagious skin condition caused by mites burrowing into the skin, so applying the lotion to all skin areas helps to eliminate the mites and prevent reinfestation. It is important to follow the instructions provided by the healthcare professional for proper application and treatment of scabies.

Correct Answer: A

Rationale: Nursing intervention should prioritize providing education on proper incisional wound care techniques to promote optimal healing of the abdominal incision. This may include instructions on how to clean the incision site, signs and symptoms of infection, and when to seek medical attention. Proper wound care can help prevent complications such as infection and dehiscence, leading to better outcomes for the client. Administering prophylactic antibiotics, encouraging the use of abdominal binders, and instructing the client on activity restrictions are also important interventions, but educating the client on wound care techniques is crucial for their active participation in their recovery process.

Correct Answer: A

Rationale: Statement II is correct because the use of corticosteroids for multiple immune conditions can lead to the development of Cushing's disease.