Foundations and Adult Health Nursing Study Guide Answers

Correct Answer: C

Rationale: Type 2 diabetes mellitus is characterized by insulin resistance in the peripheral tissues and defective beta cell secretion with loss of insulin. In type 2 diabetes, there is typically not destruction of beta cells from an autoimmune mechanism that leads to lack of insulin and hyperglycemia as seen in type 1 diabetes mellitus. Instead, in type 2 diabetes, the pancreas initially produces insulin, but the body's cells become resistant to its effects. This results in hyperglycemia due to the inability of the body to properly regulate blood sugar levels. Therefore, choice C is not true for type 2 diabetes mellitus.

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: B

Rationale: Encouraging the patient to practice controlled coughing techniques would be the most appropriate intervention to address the symptoms of chronic cough and excessive sputum production in a patient with end-stage COPD receiving palliative care. Controlled coughing techniques can help the patient effectively clear respiratory secretions and improve airway clearance without the need for additional medications or interventions. This approach focuses on optimizing the patient's ability to manage their symptoms and maintain comfort, which aligns with the goals of palliative care. Administering bronchodilator medications, prescribing mucolytic medications, or referring the patient to a respiratory therapist for breathing exercises may have limited effectiveness in this advanced stage of the disease, and controlled coughing techniques would be a more practical and patient-centered approach to symptom management.

Correct Answer: A

Rationale: The best response of Nurse Virgo is to explain to Patient Benito that his body needs to function well with his pancreas. The pancreas plays a critical role in the digestive system by producing digestive enzymes and hormones that help regulate blood sugar levels. Removing the pancreas would result in serious health consequences and complications, as the body relies on it for essential functions. It is important for the patient to understand the significance of the pancreas and why its removal is not a viable solution.

Correct Answer: C

Rationale: If the nurse observes an unusual odor emanating from the surgical site during surgery, it is important to inform the surgeon immediately and assess for signs of infection. Changes in odor can sometimes be an early sign of infection, which requires prompt attention and intervention. By communicating with the surgeon and conducting a thorough assessment, the nurse can help ensure the timely detection and management of any potential complications, such as infection, that may be affecting the patient's surgical outcome. Prompt action in response to unusual observations is crucial to maintaining patient safety and well-being during surgical procedures.