Medical Surgical Nursing Concepts and Practice Test Bank

Correct Answer: B

Rationale: In eclampsia, seizures can occur due to the underlying hypertensive crisis affecting the brain. A classic grand mal seizure consists of two phases: the tonic phase and the clonic phase. During the tonic phase, there is a sudden loss of consciousness and muscle tone, leading to the person falling down. The clonic phase follows the tonic phase and is characterized by rhythmic, repetitive muscle contractions and relaxation. Therefore, the accurate statement about the characteristics of a grand mal seizure in the context of eclampsia is that the clonic phase is evidenced by muscular contraction and rigidity.

Correct Answer: D

Rationale: Phantom limb sensation is a common phenomenon where a patient perceives sensations such as cramping, itching, or pain in the limb that has been amputated. This occurs because the brain continues to receive signals from the nerves that originally innervated the amputated limb, leading to the perception of sensation in the absent body part. In this case, the patient's complaint of toes cramping in the amputated foot is indicative of phantom limb sensation rather than contractures, attention-seeking behavior, or chronic stump pain. It is important for the nurse to educate the patient about this phenomenon and provide appropriate support and reassurance.

Correct Answer: B

Rationale: In eclampsia, seizures can occur due to the underlying hypertensive crisis affecting the brain. A classic grand mal seizure consists of two phases: the tonic phase and the clonic phase. During the tonic phase, there is a sudden loss of consciousness and muscle tone, leading to the person falling down. The clonic phase follows the tonic phase and is characterized by rhythmic, repetitive muscle contractions and relaxation. Therefore, the accurate statement about the characteristics of a grand mal seizure in the context of eclampsia is that the clonic phase is evidenced by muscular contraction and rigidity.

Correct Answer: D

Rationale: Disseminated intravascular coagulation (DIC) is a serious condition characterized by both excessive clotting and bleeding throughout the body. The primary goal of care for a client with DIC is to manage and balance the clotting and bleeding tendencies. A key indicator of successful care for a client with DIC is the absence of bleeding, as this suggests that the coagulation process has been stabilized and there is no ongoing clot breakdown leading to bleeding. Monitoring for signs of bleeding, such as petechiae, purpura, ecchymosis, hematuria, and gastrointestinal bleeding, is essential in evaluating the effectiveness of care in a client with DIC. Therefore, the absence of bleeding is the most significant finding that indicates successful care in a client with DIC.

Correct Answer: B

Rationale: The client who is postoperative from a major surgery, such as femur fracture repair, is at the highest risk for a nonthrombotic pulmonary embolism (PE). Postoperative clients are at an increased risk due to factors such as immobility, surgical trauma, and possible venous stasis. Additionally, major orthopedic surgeries involving the lower extremities carry a higher risk of developing a PE because of the potential for blood clots to form in the veins of the legs (deep vein thrombosis) and then travel to the lungs, leading to a pulmonary embolism. Close monitoring and preventative measures, such as early ambulation, compression devices, and anticoagulant therapy, are crucial in preventing this serious complication in postoperative clients.