Concepts for Nursing Practice Test Bank

Correct Answer: A

Rationale: 1. Tachycardia: Disseminated intravascular coagulation (DIC) can lead to widespread clotting within the blood vessels, which can result in tissue ischemia and subsequent compensatory mechanisms such as tachycardia to increase cardiac output and maintain perfusion.

Correct Answer: B

Rationale: Option B, "Demonstrates care of the vascular access device for dialysis," indicates that the patient understands how to care for their vascular access device, which is important for receiving dialysis treatment. This action shows adequate comprehension and competency in managing this aspect of their care. Therefore, additional teaching is not necessary in this area. On the other hand, options A, C, and D present actions that may require further clarification or reinforcement in the teaching provided to the patient with acute glomerulonephritis.

Correct Answer: D

Rationale: Hemophilia is a genetic disorder that impairs the blood's ability to clot properly, leading to prolonged bleeding. This makes individuals with hemophilia particularly susceptible to hemorrhagic shock, which is a type of distributive shock. Distributive shock occurs when there is widespread vasodilation and increased vascular permeability, leading to inadequate tissue perfusion and oxygen delivery. In the case of hemophilia, excessive bleeding can result in a significant loss of blood volume and impaired circulation, eventually leading to distributive shock due to the body's inability to maintain adequate perfusion to vital organs. Therefore, individuals with hemophilia are at an increased risk of developing distributive shock, specifically hemorrhagic shock, if they experience severe bleeding events.

Correct Answer: B

Rationale: B. Coach in nonpharmacologic pain management techniques: The client's vital signs indicate they may be experiencing pain as evidenced by an elevated heart rate (P 119), which can be addressed initially with nonpharmacologic pain management techniques. This approach can help reduce pain and anxiety without the immediate need for medication.

Correct Answer: A

Rationale: The appropriate question for the nurse to ask the mother in this scenario is "Did you consume any alcohol before you knew you were pregnant?" This is because maternal alcohol consumption during pregnancy is a known risk factor for congenital heart defects. By asking this question, the nurse can gather crucial information to determine a potential cause for the baby's condition. It is important to address this potential risk factor to provide appropriate care and support to the mother and baby.