Foundations and Adult Health Nursing Study Guide Answers

Correct Answer: D

Rationale: When a patient is crying and continuously pulling at a specific body part, such as Catherine pulling her right ear, it indicates discomfort or pain in that area. Nurse Selma's most appropriate action would be to further assess the description and frequency of the pain. This will help her identify the possible cause of the pain, whether it is due to an ear infection, injury, or any other underlying issue. Understanding the nature and intensity of the pain will guide Nurse Selma in providing appropriate care and intervention for Catherine. It is crucial to address the patient's pain promptly to ensure their comfort and well-being. Referring to the attending physician may be necessary after this initial assessment but assessing the pain should be the immediate priority.

Correct Answer: B

Rationale: The constellation of severe lower abdominal pain, fever, and vaginal discharge in a pregnant woman raises suspicion for pelvic inflammatory disease (PID). Cervical motion tenderness and adnexal tenderness are classic physical exam findings for PID. The presence of bilateral adnexal masses further supports the diagnosis, as PID can lead to the formation of tubo-ovarian abscesses. Ectopic pregnancy may present with similar symptoms but is less likely in this case as bilateral adnexal masses suggest a more diffuse inflammatory process. Placenta previa would typically present with painless vaginal bleeding in the third trimester, which is not consistent with the symptoms described. Ovarian torsion would present with sudden severe unilateral lower abdominal pain and is less likely to involve both ovaries simultaneously.

Correct Answer: B

Rationale: Offering reassurance and encouragement to the patient demonstrates therapeutic communication by the nurse. In this situation, the nurse shows empathy and understanding towards the patient's concerns about the upcoming surgical procedure, which can help alleviate anxiety and build trust. Providing reassurance and encouragement can help the patient feel supported and understood, creating a positive and therapeutic interaction between the nurse and the patient. This approach fosters open communication and helps establish a therapeutic nurse-patient relationship, which is essential for effective patient care.

Correct Answer: B

Rationale: Maternal anxiety can contribute to a prolonged latent phase during labor. Stress and anxiety can trigger the release of stress hormones such as adrenaline, which can interfere with the production of oxytocin, the hormone responsible for initiating contractions. This can result in irregular and ineffective contractions, leading to a prolonged latent phase. It is important for the nurse to assess the woman's anxiety levels and provide reassurance and support to help facilitate the progression of labor.

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.