Giddens Concepts for Nursing Practice Test Bank

Correct Answer: A

Rationale: Given the client's history of type II diabetes mellitus, chronic hypertension, and recent myocardial infarction, the most likely type of shock for the nurse to be prepared to treat in this client is cardiogenic shock. Cardiogenic shock occurs when the heart is unable to pump effectively, leading to inadequate perfusion of vital organs. This can be a complication of myocardial infarction, as damage to the heart muscle can impair its ability to pump blood effectively. Patients with a history of diabetes and hypertension are at increased risk for cardiovascular diseases, such as myocardial infarction, which can lead to cardiogenic shock. Symptoms of cardiogenic shock include hypotension, tachycardia, cool and clammy skin, and altered mental status. Treatment may involve medications to support cardiac function, such as inotropes, and interventions to improve oxygen delivery, such as oxygen therapy and fluid administration.

Correct Answer: B

Rationale: As individuals age, particularly older women, there tends to be a decrease in facial hair growth. This change is considered a normal part of the aging process and an expected age-related change in the endocrine system. The other options presented, including normal heart tones, thyroid nodules, and an enlarged and firm pituitary gland, are not typically associated with normal aging of the endocrine system.

Correct Answer: A

Rationale: 1. Pulses absent in the extremity with the wound (Option A): In chronic venous insufficiency, damaged valves in the veins result in blood pooling in the lower extremities. This can lead to decreased arterial perfusion and impaired circulation, causing weakened or absent pulses in the affected extremity.

Correct Answer: C

Rationale: Following surgery, a patient not voiding for 12 hours raises concerns for urinary retention, especially if the patient was catheterized during the surgical procedure. With urinary retention, the bladder can become distended and palpating for bladder distention can help determine if the patient is experiencing this issue. If the bladder is distended, interventions may be needed to address the urinary retention to prevent complications such as urinary tract infection or bladder distention-related discomfort. The other assessment options (percuting for gastric tympany, auscultating for bowel sounds, inspecting for edema of the urethra) are not as relevant in assessing a patient's urinary status post-surgery.

Correct Answer: C

Rationale: Teaching relaxation techniques related to perfusion can be independently performed by a nurse without requiring supervision or intervention from a healthcare provider. This nursing intervention focuses on promoting stress reduction and improving overall perfusion by enhancing circulation and decreasing the workload of the heart. The nurse can educate the patient on various relaxation techniques such as deep breathing exercises, guided imagery, progressive muscle relaxation, and meditation to help optimize perfusion levels. Additionally, teaching relaxation techniques empowers the patient to actively participate in their care and improve their overall well-being.