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: C

Rationale: Documenting the client's questions after the teaching session is important because it demonstrates the client's understanding of the information provided during the teaching session. It also helps to identify any areas where the client may need further clarification or education. This information is crucial for evaluating the effectiveness of the teaching session and ensuring that the client is able to perform tracheostomy care safely and effectively. Additionally, documenting the client's questions allows for continuity of care by providing insight into the client's concerns and educational needs.

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: A

Rationale: The statement "Nicotine causes vasospasms, which reduce blood flow to the legs" is the most appropriate response when discussing risk factors for PVD with a client who is obese, has a history of smoking, and works as a contractor. Nicotine in cigarette smoke can lead to constriction or narrowing of blood vessels, including those in the legs, which can reduce blood flow to the lower extremities. This can contribute to the development and progression of peripheral vascular disease (PVD) in individuals with a history of smoking. Identifying and educating the client about this specific risk factor related to their smoking history is important in managing their condition and preventing further complications.

Correct Answer: A

Rationale: Morning headaches that extend into the neck and subside as the day progresses can be indicative of elevated blood pressure, which is a common cause of morning headaches. Increased blood pressure can cause headaches that are usually worse in the morning due to the body's natural circadian rhythms. Monitoring the client's blood pressure and assessing for other signs of hypertension would be important in this case. Tachycardia, otitis media, and swollen lymph nodes are less likely to be associated with the described symptoms.