Concept Based Nursing Practice Questions

Correct Answer: A

Rationale: Congenital heart defects typically develop during the first 8 weeks of gestation when the baby's heart is forming. This is a critical period of organogenesis, where the heart undergoes complex development and any disruptions during this time can lead to structural abnormalities in the heart. Factors such as genetics, environmental influences, and certain maternal health conditions can contribute to the development of congenital heart defects during this early stage of pregnancy. It is crucial for mothers to receive proper prenatal care to help reduce the risk of congenital heart defects and other birth abnormalities.

Correct Answer: D

Rationale: Osteoarthritis is a condition where the protective cartilage that cushions the ends of bones wears down over time. Excess weight puts extra stress on the joints, particularly weight-bearing joints like the knees. Being overweight by 30 pounds increases the risk of developing osteoarthritis in the knees because the added weight can accelerate the breakdown of cartilage. Therefore, the nurse identified the patient as at risk for osteoarthritis due to being overweight by 30 pounds.

Correct Answer: A

Rationale: When teaching an adult client with high cholesterol, it is important for the nurse to consider that adults are more oriented to learning when the material is useful immediately. This means that providing practical information and emphasizing how managing high cholesterol can benefit their health in the short term is likely to be more effective in engaging the client and encouraging adherence to recommendations. By focusing on the immediate relevance and benefits of the information, the nurse can enhance the client's motivation and understanding of the importance of managing their high cholesterol levels.

Correct Answer: D

Rationale: A blood pressure reading of 142/92 mmHg falls into the category of Hypertension Stage II based on the guidelines from the American Heart Association. In this classification, systolic blood pressure is 140-159 mmHg and diastolic blood pressure is 90-99 mmHg. Stage II hypertension indicates that the individual has a significantly elevated blood pressure level that requires prompt management and monitoring. It is crucial for the nurse to document this accurately to ensure appropriate interventions are provided to the client.

Correct Answer: C

Rationale: In a client with deep venous thrombosis (DVT), the priority problem would be peripheral perfusion. DVT is a condition where a blood clot forms in a vein deep within the body, usually in the lower extremities. This clot can impede blood flow in the affected vein, leading to compromised circulation to the surrounding tissues. Poor peripheral perfusion can result in tissue ischemia and potential tissue necrosis. Monitoring and ensuring adequate peripheral perfusion is crucial to prevent tissue damage and further complications such as pulmonary embolism. Therefore, addressing and improving peripheral perfusion would be the priority in caring for a client with DVT.