Nursing a Concept Based Approach Test Bank

Correct Answer: A

Rationale: Cloudy urine following a kidney transplant may be a common occurrence and could be due to various factors such as dehydration, medication side effects, or the presence of mucus, cells, or proteins in the urine. The nurse should first record the finding and then further assess the patient by checking for other signs and symptoms like pain, fever, or abnormal odors in the urine. If the cloudy urine is persistent or accompanied by other concerning symptoms, then the nurse should notify the physician for further evaluation. However, initially recording the finding allows for documentation and monitoring of the patient's condition, providing a baseline for further assessment and intervention if necessary. It is important to remember that cloudy urine alone may not always indicate a serious issue, but thorough assessment and documentation are essential steps in ensuring the patient's well-being.

Correct Answer: C

Rationale: When teaching about the type of injury of an amputated digit, the nurse should include the proper handling of the amputated part. The correct method is to wrap the amputated digit in a clean towel, place it in a sealed plastic bag to prevent direct contact with ice, and then place the bag on ice. Placing the amputated digit directly on ice can cause frostbite and further damage to the tissue. By following this method, the amputated digit can be preserved properly until medical help is received. Transporting the person to the hospital is important but proper handling of the amputated digit is critical to increase the chances of successful reattachment. Placing the amputated digit in warm water or taping it to the hand are not recommended methods for preserving an amputated digit.

Correct Answer: D

Rationale: Addressing any healing beliefs the family has should be a priority for the nurse in developing a teaching plan for the child with asthma. The family's cultural beliefs and practices may influence their understanding and acceptance of medical treatments. By understanding and respecting the family's beliefs, the nurse can tailor the teaching plan to align with the family's values and ensure better adherence to the treatment plan. This approach promotes effective communication, trust, and collaboration between the healthcare team and the family, which is essential for the child's recovery and ongoing management of asthma. Providing culturally sensitive care is crucial in improving health outcomes and promoting family-centered care in a diverse healthcare setting.

Correct Answer: A

Rationale: The most important thing to remember regarding the warning signs of stroke is to "be alert for sudden weakness or numbness." This is crucial because sudden weakness or numbness in the face, arm, or leg, especially on one side of the body, is one of the hallmark symptoms of a stroke. It is essential to recognize these signs promptly and seek immediate medical attention to minimize the potential damage caused by a stroke. Being aware of these sudden symptoms can help individuals receive timely treatment and improve their chances of recovery.

Correct Answer: D

Rationale: In a client with preeclampsia, one of the laboratory values that the nurse might anticipate is an increased serum creatinine level. Preeclampsia is a hypertensive disorder of pregnancy characterized by high blood pressure and involvement of multiple organ systems, including the kidneys. An elevated serum creatinine level indicates impaired kidney function, as creatinine is a waste product that is normally filtered by the kidneys and excreted in the urine. In preeclampsia, reduced kidney perfusion due to the high blood pressure can lead to decreased glomerular filtration rate, resulting in elevated serum creatinine levels. Monitoring serum creatinine is essential in assessing kidney function and guiding management in clients with preeclampsia.