Foundations and Adult Health Nursing Study Guide Answers

Correct Answer: B

Rationale: The 5's strategy to prevent dengue infection includes Search and Destroy mosquito breeding places, seek early consultation at the nearest health care facility, say no to fogging spraying, and misting in hot spot areas. While using mosquito repellent on exposed skin is a common preventive measure against mosquito bites, applying it all over your body is not included in the official 5's strategy for dengue prevention. The focus of the 5's strategy is on eliminating mosquito breeding sites, seeking medical advice early in case of symptoms, and avoiding certain mosquito control methods like fogging in hot spot areas.

Correct Answer: C

Rationale: The most appropriate nursing action in this scenario is to notify the healthcare provider immediately. The client's presentation of calf pain, swelling, and warmth could be indicative of a deep vein thrombosis (DVT), which is a serious condition that requires prompt evaluation and intervention by the healthcare provider. DVT is a blood clot that forms in a deep vein, often in the leg, and if left untreated, it can lead to life-threatening complications such as pulmonary embolism. Therefore, timely communication with the healthcare provider is critical to ensure that the client receives the appropriate diagnostic testing and treatment to address the potential DVT. Applying warm compresses, encouraging ambulation, or administering NSAIDs would not be the first-line interventions for a suspected DVT and may even worsen the condition.

Correct Answer: A

Rationale: When a patient is receiving too much insulin, the most likely result is hypoglycemia, not hyperglycemia. The excess insulin causes the blood glucose level to drop too low, leading to symptoms such as sweating, tremors, confusion, and in severe cases, seizures. The body responds to hypoglycemia by releasing counterregulatory hormones such as glucagon, epinephrine, and cortisol, which work to increase the blood glucose level. This rebound effect, known as the Somogyi effect, can result in the patient experiencing high blood glucose levels after a period of insufficient glucose supply due to excessive insulin administration.

Correct Answer: D

Rationale: An advance directive is a legal document that specifies a person's healthcare preferences and instructions for medical treatment in the event they are unable to communicate their wishes. It typically includes decisions about life-sustaining treatments, resuscitation, and end-of-life care. In the scenario provided, the document provided by the patient to the nurse outlining his healthcare team's instructions postoperatively indicates that he has an advance directive in place to guide his medical care if necessary. In contrast, informed consent is a process in which a patient gives permission for medical treatment after being informed about the risks, benefits, and alternatives. Patient's Bill of Rights outlines the patient's rights within the healthcare system, and an insurance card provides information about the patient's insurance coverage.

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.