Foundations and Adult Health Nursing Study Guide Answers

Correct Answer: D

Rationale: The initial step in the process of change for the senior nurse should be to identify the inefficiency that needs improvement or correction. Before setting goals, planning strategies, or identifying solutions, it is essential to first pinpoint the specific area or aspect that requires change. By identifying the inefficiency, the senior nurse can gain a clear understanding of the root cause of the issue and focus efforts on addressing it effectively. This step lays the foundation for the rest of the change process by providing a specific target for improvement.

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: In the scenario described, the patient is experiencing severe hypoxemia refractory to conventional oxygen therapy, indicating a need for advanced respiratory support. When a patient with ARDS fails to respond to conservative management, including mechanical ventilation strategies, prone positioning, and recruitment maneuvers, the next step may involve extracorporeal membrane oxygenation (ECMO). ECMO provides a way to bypass the lungs and oxygenate the blood directly, allowing for enhanced gas exchange and support for severely compromised respiratory function. Therefore, in this critical situation, prioritizing the recommendation for ECMO can offer the patient the best chance of improving oxygenation and survival.

Correct Answer: D

Rationale: When a patient is admitted to the OB ward with complaints of dizziness and body weakness, this information pertains to what the patient is feeling or experiencing, which is subjective data. Subjective data is based on the patient's symptoms, feelings, and experiences as reported by the patient themselves. In this case, dizziness and body weakness are subjective symptoms described by the patient, and they cannot be objectively measured or quantified. It is essential for healthcare providers to consider subjective data along with objective data (measurable and observable signs) when assessing and diagnosing a patient's condition.

Correct Answer: D

Rationale: Nursing diagnosis is the tool used by nurses in the community setting for assessing health needs and problems of families that is similar to the family coping index. Nursing diagnosis involves systematic assessment of a patient's health status, analysis of data, and identification of actual or potential health problems. Just like the family coping index, nursing diagnosis helps nurses to identify key issues and develop a plan of care that addresses the specific needs and challenges faced by the family. This process allows nurses to provide individualized care that supports the family in coping with their health needs and improving their overall well-being.