Medical Surgical Nursing Concepts and Practice Test Bank

Correct Answer: D

Rationale: Phantom limb sensation is a common phenomenon where a patient perceives sensations such as cramping, itching, or pain in the limb that has been amputated. This occurs because the brain continues to receive signals from the nerves that originally innervated the amputated limb, leading to the perception of sensation in the absent body part. In this case, the patient's complaint of toes cramping in the amputated foot is indicative of phantom limb sensation rather than contractures, attention-seeking behavior, or chronic stump pain. It is important for the nurse to educate the patient about this phenomenon and provide appropriate support and reassurance.

Correct Answer: B

Rationale: The client who is postoperative from a major surgery, such as femur fracture repair, is at the highest risk for a nonthrombotic pulmonary embolism (PE). Postoperative clients are at an increased risk due to factors such as immobility, surgical trauma, and possible venous stasis. Additionally, major orthopedic surgeries involving the lower extremities carry a higher risk of developing a PE because of the potential for blood clots to form in the veins of the legs (deep vein thrombosis) and then travel to the lungs, leading to a pulmonary embolism. Close monitoring and preventative measures, such as early ambulation, compression devices, and anticoagulant therapy, are crucial in preventing this serious complication in postoperative clients.

Correct Answer: C

Rationale: In a pregnant woman, a hematocrit level of 24% is cause for concern as it is lower than the normal range during pregnancy. A lower than normal hematocrit level may indicate anemia in the pregnant woman, which can lead to complications for both the mother and the baby. Anemia during pregnancy can result in inadequate oxygen reaching the tissues, fatigue, increased risk of preterm birth, and low birth weight for the baby. Therefore, this finding should be further evaluated and managed promptly to ensure the well-being of the pregnant woman and her baby.

Correct Answer: A

Rationale: Patients with hypothyroidism often exhibit rough, dry skin as a result of decreased thyroid hormone levels impacting the skin's ability to retain moisture. This condition, known as myxedema, can lead to skin changes such as dryness, scaling, and thickening. The skin may also appear pale or yellowish due to reduced blood flow. Therefore, the nurse should expect the patient with newly diagnosed hypothyroidism to present with rough, dry skin during assessment.

Correct Answer: B

Rationale: It is crucial for parents to be instructed on preventing exposure to infection before their baby's surgery to correct a congenital heart defect. Infections can pose a serious risk to individuals, especially those with preexisting medical conditions like a congenital heart defect. Infection control measures, such as handwashing, avoiding sick contacts, and keeping the environment clean, can help reduce the risk of postoperative complications due to infections. This instruction is important to help ensure the successful outcome of the baby's surgery and recovery process. It is essential for parents to be vigilant in maintaining a hygienic environment and taking necessary precautions to prevent their baby from getting sick prior to the surgery.