Foundations and Adult Health Nursing Study Guide Answers

Correct Answer: B

Rationale: Phlebitis is the most common complication that patients may contract while on IV therapy. Phlebitis is the inflammation of the vein where the IV is inserted, which can cause redness, pain, and swelling along the vein. It can be caused by mechanical irritation, chemical irritation, or infection from the IV catheter. Prompt removal of the IV catheter and appropriate treatment are necessary to manage phlebitis and prevent further complications. While embolism, cardiac overload, and aneurysm are potential complications of IV therapy, phlebitis is more commonly seen in clinical practice.

Correct Answer: A

Rationale: Research at work is an example of self-directed learning activity because it involves taking the initiative to seek out information, learn new skills, and solve problems independently within a workplace setting. This type of learning requires self-motivation, self-discipline, and autonomy to set goals, gather resources, and develop knowledge or expertise in a specific area. Individuals engage in research at work to enhance their professional growth, expand their skill set, or address challenges encountered in their job responsibilities. It is a proactive approach to learning where individuals take charge of their own development and continuously strive to improve their performance.

Correct Answer: A

Rationale: Acute splenic sequestration crisis is a complication seen in patients with sickle cell disease characterized by the sudden pooling of sickled red blood cells in the spleen, leading to splenic enlargement, severe anemia, and hypovolemic shock. This pooling results in a rapid drop in hemoglobin levels, causing anemia. The spleen's sequestration of large numbers of red blood cells can cause a sudden rise in the number of immature red blood cells (reticulocytes) in the blood (reticulocytosis). The destruction of these trapped red blood cells in the spleen leads to hemolysis, evidenced by elevated indirect bilirubin levels and the presence of Howell-Jolly bodies (nuclear remnants of erythrocytes) on peripheral blood smear. Patients may present with severe abdominal pain, fever, jaundice, and signs of hemodynamic instability, which

Correct Answer: A

Rationale: The most appropriate nursing diagnosis for this patient would be "Self-care deficit related to neuromuscular impairment." This diagnosis is supported by the information provided, which indicates that the patient is experiencing neuromuscular impairment that is likely affecting their ability to perform self-care activities. A self-care deficit diagnosis is relevant when a patient is unable to perform activities of daily living independently due to physical or cognitive limitations. In this case, the neuromuscular impairment is likely impacting the patient's ability to engage in self-care tasks, such as feeding, grooming, bathing, and dressing. By identifying and addressing this self-care deficit, the healthcare team can help the patient maintain optimal functioning and independence despite their neuromuscular impairment.

Correct Answer: A

Rationale: The parotid gland is the salivary gland that is located superior and anterior to the ear. It mainly produces serous saliva, which is a thin, watery fluid rich in enzymes. The other salivary glands mentioned are the sublingual gland, submandibular gland, and submaxillary gland, all of which have different locations and produce different types of saliva.