Foundations and Adult Health Nursing Study Guide Answers

Correct Answer: A

Rationale: Somatic hypermutation is the mechanism responsible for generating diversity in the antigen-binding sites of immunoglobulins. During somatic hypermutation, point mutations are introduced into the variable regions of immunoglobulin genes in B cells. These mutations occur randomly and lead to a wide range of amino acid changes in the antigen-binding sites of antibodies. As a result, a diverse repertoire of antibodies with varying specificities for different antigens is created. Gene rearrangement and isotype switching are other mechanisms that contribute to antibody diversity but do not specifically target the antigen-binding sites. Clonal expansion, on the other hand, refers to the proliferation of specific B cell clones after activation by antigens, which amplifies the immune response but does not directly impact the diversity of antigen-binding sites.

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.

Correct Answer: C

Rationale: When working with Sandro, who is taking an MAOI and needs to be educated on avoiding foods with tyramine, the nursing diagnosis commonly used would be "impaired social interaction." This nursing diagnosis focuses on the client's difficulty in establishing or maintaining meaningful relationships with others. In this case, Sandro's dietary restrictions due to his medication may cause challenges in social situations, leading to potential feelings of isolation or inability to engage in social activities involving food. By identifying impaired social interaction as a nursing diagnosis, the nurse can address these issues and support Sandro in maintaining social connections while adhering to his dietary requirements.

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: D

Rationale: An advance directive is a legal document that specifies a person's healthcare preferences and instructions for medical treatment in the event they are unable to communicate their wishes. It typically includes decisions about life-sustaining treatments, resuscitation, and end-of-life care. In the scenario provided, the document provided by the patient to the nurse outlining his healthcare team's instructions postoperatively indicates that he has an advance directive in place to guide his medical care if necessary. In contrast, informed consent is a process in which a patient gives permission for medical treatment after being informed about the risks, benefits, and alternatives. Patient's Bill of Rights outlines the patient's rights within the healthcare system, and an insurance card provides information about the patient's insurance coverage.