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Foundations and Adult Health Nursing Study Guide Answers Questions
Question 1 of 9
A patient presents with chest pain that worsens with exertion and improves with rest. An electrocardiogram (ECG) shows ST-segment depression. Which cardiovascular disorder is most likely responsible for these symptoms?
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.
Question 2 of 9
Nurse Pat promised to a post- surgical patient, that she would come back to assist in his of ambulation after carrying out the physician's order. This follows the principle
Correct Answer: D
Rationale: Fidelity is a principle in nursing ethics that pertains to being faithful or loyal to commitments and promises made to patients. When Nurse Pat promised to come back to assist in the patient's ambulation after carrying out the physician's order, she is demonstrating fidelity by fulfilling her commitment to the patient's care. This principle helps build trust between the nurse and the patient, ensuring continuity and quality of care.
Question 3 of 9
An infant's current weight indicates that the maximum safe dose of Tylenol is 30 mg by mouth. The physician orders 65 mg to be given, the pharmacist is responsible for filling the medication order, and the nurse administers Tylenol 65 mg. Who is legally responsible in the event that the infant has a toxic reaction to the medication?
Correct Answer: C
Rationale: The pharmacist is legally responsible in this situation because they are the healthcare professional authorized to dispense medications according to the physician's order. In this case, the physician ordered a dose higher than the maximum safe dose recommended based on the infant's current weight. While the nurse administers the medication, the pharmacist has the responsibility to ensure that the correct dose is dispensed and to alert the physician if there is a discrepancy in the order. If the pharmacist dispensed the incorrect dose without verifying with the physician, they would bear legal responsibility for any adverse effects resulting from the medication error.
Question 4 of 9
Endocrine changes often result in a bulimic patient. Which of the following would be an expected change in Sherry?
Correct Answer: C
Rationale: Endocrine changes in a bulimic patient, such as Sherry, can lead to disruptions in the pituitary gland's function. Hypopituitarism refers to a disorder in which the pituitary gland does not produce one or more of its hormones adequately. This can result in hormonal imbalances and have various effects on the body's functions. In Sherry's case, developing hypopituitarism would be an expected change due to the endocrine disruptions associated with bulimia. It is important for healthcare providers to monitor and address these endocrine changes in bulimic patients to prevent further complications.
Question 5 of 9
What nursing diagnosis would be MOST appropriate for a client admitted with heart failure?
Correct Answer: B
Rationale: Heart failure is a condition in which the heart is unable to pump enough blood to meet the body's need for oxygen and nutrients. Ineffective tissue perfusion is a relevant nursing diagnosis for a client with heart failure because the heart's inability to effectively pump blood can lead to poor perfusion of tissues and organs, resulting in inadequate oxygen and nutrient delivery to cells. This can lead to symptoms such as fatigue, dyspnea, and edema, which are common in individuals with heart failure. By addressing ineffective tissue perfusion, nurses can focus on interventions to improve cardiac output and optimize tissue perfusion, ultimately improving the client's overall condition.
Question 6 of 9
A patient with a history of sickle cell disease presents with severe abdominal pain, fever, and jaundice. Laboratory tests reveal anemia, reticulocytosis, elevated indirect bilirubin, and presence of Howell-Jolly bodies on peripheral blood smear. Which of the following conditions is most likely to cause these findings?
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
Question 7 of 9
One evening, Jose complained of dyspnea despite continuous oxygen therapy. What should be the nurse's INITIAL intervention?
Correct Answer: C
Rationale: If Jose is complaining of dyspnea despite continuous oxygen therapy, the nurse's initial intervention should be to assess the patency of the tubing delivering the oxygen. A blockage in the tubing could restrict the flow of oxygen to the patient, leading to inadequate oxygen delivery and worsening dyspnea. By ensuring the tubing is clear and functioning properly, the nurse can address a potential issue with oxygen delivery before considering other interventions like giving PRN medication or involving the physician. Re-assessing the patient would also be important after ensuring the tubing's patency to evaluate the effectiveness of the intervention.
Question 8 of 9
In the universal health law, which of the following are the government agencies that are considered as "key players" in its implementation?
Correct Answer: B
Rationale: In the universal health law, the government agencies that are considered as "key players" in its implementation are the Department of Health (DOH), Local Government Units (LGUs), and the Philippine Health Insurance Corporation (PhilHealth).
Question 9 of 9
A patient with a history of coronary artery disease is prescribed aspirin for secondary prevention. Which adverse effect is a potential concern with long-term aspirin therapy?
Correct Answer: B
Rationale: Long-term aspirin therapy, especially at higher doses, can increase the risk of gastrointestinal bleeding. Aspirin irreversibly inhibits cyclooxygenase enzyme, which is essential for the production of prostaglandins involved in mucosal protection of the gastrointestinal tract. Without these protective prostaglandins, the stomach lining becomes more susceptible to damage from gastric acid, leading to potential ulcer formation and bleeding. Patients with a history of coronary artery disease may be on aspirin for secondary prevention, and it is crucial to monitor for signs of bleeding such as black, tarry stools or abdominal pain. The benefits of aspirin in preventing cardiovascular events need to be weighed against the risk of adverse effects like gastrointestinal bleeding, especially in patients on long-term therapy.