Fundamental Concepts and Skills for Nursing Test Questions

Correct Answer: C

Rationale: Aphasia, which is the inability to understand or express speech, is typically associated with damage to the left hemisphere of the brain. In a client with suspected transient ischemic attack (TIA) presenting with aphasia, the nurse would plan care based on ischemia affecting the left hemisphere of the brain. The left hemisphere is responsible for language processing in most individuals, so damage in this area can result in communication deficits such as aphasia.

Correct Answer: D

Rationale: Early preeclampsia is a condition characterized by high blood pressure and signs of damage to another organ system, commonly the liver and kidneys. Severe epigastric pain is a common symptom of this organ involvement. It is caused by liver distention due to the breakdown of red blood cells and platelets, which can lead to a condition known as HELLP syndrome. This manifestation is a significant indicator of early preeclampsia and requires prompt evaluation and intervention to prevent complications for both the mother and the baby. While the other options may be present in preeclampsia, severe epigastric pain is a more specific and concerning symptom requiring immediate attention.

Correct Answer: B

Rationale: - Elevating the client's knees on the bed or with a pillow can help improve venous return and promote circulation, ultimately enhancing peripheral tissue perfusion in a client with DIC.

Correct Answer: B

Rationale: The patient's symptoms are indicative of kidney stones causing obstruction and possibly renal colic. The sudden onset of severe crampy pain on the left side radiating into the groin, along with nausea, vomiting clear fluid, and passing pink urine (hematuria) are classic signs of kidney stones. Given the severity of the symptoms and the potential for complications, it is crucial to notify the physician immediately for further evaluation and management. Straining all urine, administering analgesics, and obtaining a bladder scan may be necessary interventions but should be done after informing the physician and following their recommendations.

Correct Answer: B

Rationale: The best description of the client education the nurse is presenting in this scenario is an important independent nursing function. Nurses are responsible for educating clients on how to make lifestyle changes to promote heart health, such as following a heart-healthy diet, engaging in regular exercise, and managing stress. This education is a crucial aspect of nursing care and falls under the independent function of nurses, as it does not require a healthcare provider's order to implement. Nurses play a key role in empowering clients to take control of their health and well-being through education and support.