Nursing a Concept Based Approach to Learning Test Bank Free

Correct Answer: B

Rationale: Atrial septal defect (ASD) is a congenital heart defect where there is an abnormal opening between the atria of the heart. The manifestations of ASD can vary depending on the size of the defect and the individual. However, common manifestations may include:

Correct Answer: C

Rationale: Swelling in one leg with edema is a classic sign of deep venous thrombosis (DVT). DVT occurs when a blood clot forms in one or more of the deep veins in the body, usually in the legs. This can lead to swelling in the affected leg due to the impaired venous return caused by the blood clot. It is important for the nurse to recognize this sign because if left untreated, DVT can lead to serious complications such as pulmonary embolism. Therefore, the nurse should further assess the client and notify the healthcare provider for appropriate management.

Correct Answer: B

Rationale: Assessing postural blood pressures is important in determining if the client may be experiencing orthostatic hypotension, which could have contributed to the fall. Orthostatic hypotension is a sudden drop in blood pressure that can occur when a person stands up from a sitting or lying position. Older adults on antihypertensive medications are at increased risk for orthostatic hypotension. By monitoring postural blood pressures, the nurse can identify fluctuations in blood pressure that may put the client at risk for falls and implement appropriate interventions to prevent future falls. Monitoring serum sodium levels and creatinine levels are important for detecting electrolyte imbalances or kidney dysfunction but do not directly address the issue of orthostatic hypotension related to falls. Monitoring blood pressure every 2 hours may not provide valuable information on postural blood pressure changes that are associated with orthostatic hypotension.

Correct Answer: C

Rationale: When the nurse asks the patient to move an extremity away from the body midline, they are assessing the movement of abduction. Abduction refers to the movement of a body part away from the midline of the body. In this case, moving the extremity away from the body midline represents abduction, as the limb is being moved outward or away from the center of the body. Flexion and extension involve bending and straightening movements, respectively, along a joint axis, while adduction involves moving a body part towards the midline of the body.

Correct Answer: C

Rationale: After an embolus becomes trapped in the pulmonary microvasculature, dead space increases. Dead space refers to the portion of the lung that is ventilated but not perfused, resulting in reduced gas exchange. When a pulmonary embolus blocks blood flow within a pulmonary vessel, it leads to a mismatch between ventilation and perfusion in the affected lung region. This mismatch results in increased dead space, as ventilation continues in areas that are not effectively perfused. As dead space increases, the overall efficiency of gas exchange in the lung is impaired, potentially leading to hypoxemia.