Foundations and Adult Health Nursing Study Guide Answers

Correct Answer: A

Rationale: An open chest wound, also known as a sucking chest wound, can lead to a collapsed lung and respiratory distress. Immediate management involves sealing the wound to prevent air from entering the pleural space and further compromising the patient's respiratory function. Applying a sterile dressing over the wound helps to prevent contamination and occluding the wound with an airtight covering, such as an occlusive dressing, can effectively reduce the risk of a tension pneumothorax, a serious complication that can arise from a sucking chest wound. These interventions help to stabilize the patient's condition and improve the chances of a successful recovery. Administering supplemental oxygen, though beneficial, would be secondary to the primary management of sealing the chest wound. Providing emotional support is important but addressing the physical emergency takes precedence. Elevating the patient's legs would not be appropriate in managing an open chest wound.

Correct Answer: C

Rationale: The initial teaching given to a patient with ALS and her family should focus on explaining the disease process, the expected course, and prognosis. Providing this information early on can help the patient and her family understand what to expect, make informed decisions about care and treatment, and prepare emotionally for the challenges ahead. It is important to establish open communication and provide support from the beginning to help the patient and her family cope with the diagnosis and navigate the journey with ALS. While referral to support groups, prevention of complications, and prevention of depression are all important aspects of care for ALS patients, understanding the disease process and prognosis is fundamental to setting realistic expectations and planning for the future.

Correct Answer: B

Rationale: Marlene opening up to the nurse about their financial difficulty indicates that she feels comfortable enough to share personal information with the nurse. This signals the establishment of a trusting relationship between Marlene and the nurse, as Marlene feels safe and supported enough to disclose sensitive information. Building trust is a crucial aspect of any professional relationship, especially in healthcare settings, as it fosters open communication, encourages honesty, and ultimately leads to better outcomes for the patient. It is an essential foundation for providing effective care and support to individuals in need.

Correct Answer: C

Rationale: Mast cells are primarily responsible for mediating allergic responses such as severe allergies. When an allergen triggers the immune response, mast cells release histamine, leukotrienes, and other inflammatory mediators. These substances cause symptoms such as difficulty breathing, hives, and swelling. Basophils also release histamine, but mast cells are more abundant in tissues and play a significant role in allergic reactions. Eosinophils are involved in allergic reactions but are more focused on combating parasitic infections. Neutrophils are not typically involved in allergic responses but play a key role in combating bacterial infections.

Correct Answer: B

Rationale: The medication given after a successful vaginal delivery that helps to hasten uterine contractility and control bleeding is typically an oxytocic agent, such as oxytocin. Oxytocin helps the uterus to contract effectively, which is important for preventing excessive bleeding after delivery. This medication is commonly used in the postpartum period to help the uterus return to its normal size and position. The supervisor reassured the newly hired nurse that everything will be fine because this medication will help promote uterine contractions and control bleeding, which are crucial steps in the postpartum management.