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: The nurse is assessing the deep tendon reflexes of the patient to evaluate for signs of hyperthyroidism. In hyperthyroidism, there is an excessive production of thyroid hormones, which can lead to symptoms such as hyperactivity of the nervous system. Patients with hyperthyroidism may exhibit brisk deep tendon reflexes, along with other signs such as tremors, weight loss, heat intolerance, and tachycardia. Therefore, the nurse's assessment of deep tendon reflexes is particularly relevant in identifying signs of hyperthyroidism.

Correct Answer: B

Rationale: Elastic compression therapy, such as wearing elastic hose (compression stockings), is an essential component of managing chronic venous insufficiency. Compression stockings help improve venous return, reduce edema, and alleviate symptoms such as pain and swelling. They work by applying external pressure to the legs, promoting better circulation and preventing blood from pooling in the veins. The nurse should ensure that the client wears the compression stockings as prescribed to maximize their effectiveness in managing the condition.

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: D

Rationale: Tachycardia and nonspecific T-wave changes on the EKG are consistent with a pulmonary embolism (PE). Tachycardia is a common finding in PE, as the body tries to compensate for the decreased oxygenation due to the blockage in the pulmonary artery. Nonspecific T-wave changes, such as ST-segment abnormalities or inverted T-waves, can also be seen in patients with PE. These EKG findings, along with symptoms like dyspnea and chest pain, raise the suspicion for pulmonary embolism and warrant further diagnostic workup. Options A, B, and C are not specific findings related to a pulmonary embolism.