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: A

Rationale: A beta blocker would likely be prescribed for an older adult client diagnosed with cardiomyopathy and a cardiac dysrhythmia. Beta blockers are commonly used to manage dysrhythmias by slowing down the heart rate, reducing the workload of the heart, and improving its efficiency. They can also help in preventing arrhythmias and improving overall cardiac function in individuals with cardiomyopathy. Additionally, beta blockers have been shown to reduce mortality and improve symptoms in patients with various cardiac conditions. Therefore, it is a suitable medication choice for this client's condition.

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 nurse should emphasize the use of ice after a sprained ankle because it helps decrease the diameter of blood vessels. By applying ice to the injured area, vasoconstriction occurs, which means the blood vessels constrict and become narrower. This helps reduce swelling, inflammation, and pain associated with the injury. Cold therapy through the application of ice is a common approach used in the immediate management of sprains and strains to promote healing and alleviate discomfort.

Correct Answer: D

Rationale: The statement "My doctor told me I have a slight amount of protein in my urine" suggests that the patient has proteinuria, which is a condition where abnormal amounts of protein are found in the urine. Proteinuria can be an indication of a health problem affecting the renal system, such as kidney disease or dysfunction. This made the nurse suspect that the older female patient may have an issue with her renal system. Statements A, B, and C are common experiences related to urinary habits but do not specifically point towards a renal health problem like proteinuria does.