Foundations and Adult Health Nursing Study Guide Answers

Correct Answer: A

Rationale: A district hospital is an example of a secondary health facility. Secondary health facilities are the intermediate level of healthcare services, providing a higher level of care compared to primary health facilities like rural health units and barangay health stations. District hospitals typically offer more specialized medical services, diagnostic facilities, and inpatient care that are not available at lower-level health facilities. When Nurse Vince refers a patient to a district hospital, it means that the patient requires more extensive and specialized medical care beyond what can be provided at the primary level of care.

Correct Answer: C

Rationale: The pharmacist is legally responsible in this situation because they are the healthcare professional authorized to dispense medications according to the physician's order. In this case, the physician ordered a dose higher than the maximum safe dose recommended based on the infant's current weight. While the nurse administers the medication, the pharmacist has the responsibility to ensure that the correct dose is dispensed and to alert the physician if there is a discrepancy in the order. If the pharmacist dispensed the incorrect dose without verifying with the physician, they would bear legal responsibility for any adverse effects resulting from the medication error.

Correct Answer: B

Rationale: When communicating with a patient experiencing delirium, the nurse's priority is to provide clear and simple explanations to minimize confusion. Delirium can cause disorientation, confusion, and impaired cognitive function, making it difficult for the patient to understand complex information. Using simple language and clear explanations can help the patient better comprehend the situation and reduce anxiety. It is essential for the nurse to speak calmly, use reassuring gestures, and maintain a supportive presence to effectively communicate with a delirious patient. This approach can help establish a sense of trust and foster a therapeutic nurse-patient relationship during the challenging experience of delirium.

Correct Answer: B

Rationale: The patient's presentation of sudden-onset weakness and sensory loss on one side of the body, along with difficulty speaking and understanding speech that partially resolved within one hour, is consistent with a transient ischemic attack (TIA). TIAs are caused by temporary disruption of blood flow to a part of the brain, leading to transient neurological symptoms. Unlike an ischemic stroke, which results in permanent damage to brain tissue due to prolonged interruption of blood flow, TIAs are transient and resolve within 24 hours. Hemorrhagic strokes and subarachnoid hemorrhages typically present with sudden, severe headaches, and may not improve or resolve quickly as seen in this case.

Correct Answer: C

Rationale: When working with Sandro, who is taking an MAOI and needs to be educated on avoiding foods with tyramine, the nursing diagnosis commonly used would be "impaired social interaction." This nursing diagnosis focuses on the client's difficulty in establishing or maintaining meaningful relationships with others. In this case, Sandro's dietary restrictions due to his medication may cause challenges in social situations, leading to potential feelings of isolation or inability to engage in social activities involving food. By identifying impaired social interaction as a nursing diagnosis, the nurse can address these issues and support Sandro in maintaining social connections while adhering to his dietary requirements.