Foundations and Adult Health Nursing Study Guide Answers

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: B

Rationale: Running water in the sink or shower is a priority nursing measure to stimulate the sensation of voiding in postpartum mothers experiencing difficulty due to edema and trauma of the perineum. The sound and sight of running water can help relax the pelvic floor muscles and trigger the urge to void. This technique is commonly used in clinical practice to facilitate voiding and prevent urinary retention in postpartum women.

Correct Answer: A

Rationale: The patient is presenting with chest pain that worsens with exertion and improves with rest, which is characteristic of stable angina. Additionally, ST-segment depression on ECG is a common finding in patients with stable angina. Stable angina is typically caused by coronary artery disease, which leads to partial obstruction of the coronary arteries resulting in inadequate blood flow to the heart muscle during periods of increased demand (such as exertion). The chest pain is usually predictable and reproducible, occurring with similar intensity and duration during episodes of exertion. Rest or nitroglycerin can help relieve the symptoms by increasing coronary blood flow. It is important to differentiate stable angina from unstable angina and acute myocardial infarction, which have different management and prognostic implications.

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: B

Rationale: In a patient with chronic kidney disease presenting with metabolic acidosis, the compensatory mechanism the body is most likely to employ to normalize pH is increased bicarbonate reabsorption in the kidneys. The kidneys play a crucial role in maintaining acid-base balance by regulating bicarbonate levels in the blood. In metabolic acidosis, there is an excess of non-volatile acids in the body, leading to a decrease in blood pH. To compensate for this acidosis, the kidneys increase the reabsorption of filtered bicarbonate ions from the renal tubules back into the blood. This process helps to raise the bicarbonate levels in the blood, which in turn helps to neutralize excess hydrogen ions and restore the blood pH towards normal levels. Hyperventilation (A) is a compensatory mechanism for respiratory acidosis, not metabolic acidosis. Increased renal excretion of hydrogen ions (C) and decreased renal excretion of bicarbonate ions