Foundations and Adult Health Nursing Study Guide Answers

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: Participating in professional organizations can provide Nurse Bea with numerous opportunities to network with other professionals in the field, stay updated with the latest trends and developments in nursing, access resources for professional growth, and even participate in leadership roles within the organization. Being active in a professional organization can help Nurse Bea build her professional profile, gain recognition, and open up possibilities for career advancement and opportunities for collaboration and learning from peers. It can also help her stay connected with the broader nursing community and enhance her visibility within the field. Engaging with a professional organization is a valuable way for Nurse Bea to enhance her career alongside pursuing further education.

Correct Answer: A

Rationale: Prolonged rupture of membranes (>24 hours) increases the risk of intrauterine infection for both the mother and the fetus. When the amniotic sac has been ruptured for an extended period, there is a higher likelihood of bacteria entering the uterus, leading to chorioamnionitis (inflammation of the fetal membranes due to infection). Intrauterine infection can be dangerous for both the mother and fetus, potentially causing sepsis, preterm labor, and other complications. Therefore, it is crucial for the nurse to assess for signs and symptoms of infection in both the mother and fetus when managing a woman in active labor with prolonged rupture of membranes.

Correct Answer: D

Rationale: Nurse Rey can be liable of committing malpractice by performing circumcisions without the proper training, qualifications, and legal authority to do so. Malpractice refers to negligence or failure to provide a standard level of care that results in harm to a patient. In this case, Nurse Rey participating in performing circumcisions may not have the necessary skills and expertise compared to the doctors who are trained to perform such procedures. This can lead to potential harm or complications for the patients, making it a case of malpractice.

Correct Answer: C

Rationale: Post Transurethral Resection of the Prostate (TURP), the immediate danger that the nurse should anticipate is bleeding. TURP is a surgical procedure that involves removing portions of the prostate gland through the urethra. Due to the nature of the surgery and the rich blood supply to the prostate, bleeding is a common complication post-TURP. Excessive bleeding can lead to hypovolemic shock, which is a life-threatening condition. Therefore, monitoring for signs of bleeding, such as blood in the urine, drop in hematocrit levels, hypotension, tachycardia, and signs of hypovolemic shock, is crucial to prevent any serious complications. Proper assessment, monitoring, and timely intervention are essential in managing post-TURP bleeding and preventing adverse outcomes.