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: 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.

Correct Answer: B

Rationale: This client statement indicates that they understand the importance of making lifestyle modifications to manage hypertension. Giving up cigarettes and alcohol can significantly improve blood pressure control and overall health for someone with hypertension. It demonstrates that the client is willing to make necessary changes to help manage their condition effectively.

Correct Answer: A

Rationale: Palpation for skin turgor is used to assess the hydration status of a patient. Skin turgor is a measure of the skin's elasticity and hydration level. When a patient is well-hydrated, their skin will have good turgor, meaning it will return to its normal position quickly after being pinched. On the other hand, in a dehydrated patient, the skin will have poor turgor and will not return to its normal position promptly. Therefore, assessing skin turgor is a valuable tool for determining a patient's hydration status during a physical examination of the renal system. Palpation of both kidneys, auscultation of renal arteries, and percussion for dullness over the bladder are not specifically related to assessing hydration status.

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.