Fundamental Concepts and Skills for Nursing Test Bank

Correct Answer: B

Rationale: An increased amount of antidiuretic hormone (ADH) leads to the condition known as syndrome of inappropriate antidiuretic hormone (SIADH). This condition results in the kidneys absorbing more water, which leads to decreased urine output (oliguria) and concentrated urine. The increased ADH levels cause the body to retain fluid, leading to a decrease in urine output and potential complications such as hyponatremia (low sodium levels), which can be harmful. Increased facial hair growth or decreased testosterone production are not directly related to an overproduction of ADH.

Correct Answer: C

Rationale: Based on the blood pressure categories defined by the American Heart Association, hypertension is classified as having a systolic blood pressure (top number) of 130 mm Hg or higher and/or a diastolic blood pressure (bottom number) of 80 mm Hg or higher. The client's blood pressure reading of 150/90 mm Hg falls within the range of hypertension, indicating elevated blood pressure levels that may require monitoring and/or intervention to reduce the risk of cardiovascular complications.

Correct Answer: D

Rationale: Wheezing breath sounds in all lobes indicate airway obstruction or narrowing, which may be a sign of worsening heart failure leading to pulmonary congestion. Wheezing can be a result of fluid accumulation in the lungs (pulmonary edema) due to inadequate pumping of the heart in CHF. Monitoring for respiratory symptoms such as wheezing is crucial in assessing the effectiveness of treatment for congestive heart failure. In this case, the presence of wheezing suggests that the client's condition is not improving and requires further evaluation and intervention.

Correct Answer: D

Rationale: The nurse should emphasize the use of ice after a sprained ankle because it helps decrease the diameter of blood vessels. By applying ice to the injured area, vasoconstriction occurs, which means the blood vessels constrict and become narrower. This helps reduce swelling, inflammation, and pain associated with the injury. Cold therapy through the application of ice is a common approach used in the immediate management of sprains and strains to promote healing and alleviate discomfort.

Correct Answer: C

Rationale: Pulmonary embolism (PE) is a serious condition where a blood clot travels to the lungs and blocks blood flow, which can be life-threatening. Common clinical manifestations of PE include sudden onset of dyspnea (difficulty breathing), chest pain (sharp, stabbing pain that may worsen with deep breaths), tachypnea (rapid breathing), tachycardia (rapid heart rate), and possibly cough or hemoptysis (coughing up blood). In the context of a client recovering from a hysterectomy, it is crucial to recognize the signs of PE as early intervention is essential to prevent serious complications. Nausea, decreased urine output, and activity intolerance are not typical clinical manifestations of a pulmonary embolism and should not be the primary focus when suspecting a PE in this scenario.