Fundamental Concepts and Skills for Nursing Test Bank

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: 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: D

Rationale: The correct instruction for a client who is scheduled for temporary pacemaker insertion is to use battery-powered equipment. This is because temporary pacemakers are powered by an external power source, typically a battery pack worn by the client. Therefore, it is important for the client to be aware of this and ensure that they have access to the necessary battery-powered equipment at home for the pacemaker to function properly. The other options are not appropriate instructions for a client with a temporary pacemaker.

Correct Answer: B

Rationale: Atorvastatin (Lipitor) is a medication commonly used to treat high cholesterol levels. One of the serious side effects associated with atorvastatin use is muscle pain and weakness. This could be a sign of a rare but serious condition known as rhabdomyolysis, which is the breakdown of muscle tissue that can lead to kidney damage. Therefore, it is crucial for the client to report any muscle pain or weakness promptly to their healthcare provider to prevent any serious complications. Headaches and nausea are common side effects that may not require urgent attention. Bruising and excessive bleeding usually indicate a different issue, such as a bleeding disorder or anticoagulant medication effect. Shortness of breath and coughing are not typically associated with atorvastatin use and may suggest other health problems that require evaluation by a healthcare provider.