Nursing a Concept Based Approach Test Bank

Correct Answer: D

Rationale: Tachycardia and nonspecific T-wave changes on the EKG are consistent with a pulmonary embolism (PE). Tachycardia is a common finding in PE, as the body tries to compensate for the decreased oxygenation due to the blockage in the pulmonary artery. Nonspecific T-wave changes, such as ST-segment abnormalities or inverted T-waves, can also be seen in patients with PE. These EKG findings, along with symptoms like dyspnea and chest pain, raise the suspicion for pulmonary embolism and warrant further diagnostic workup. Options A, B, and C are not specific findings related to a pulmonary embolism.

Correct Answer: A

Rationale: The most important thing to remember regarding the warning signs of stroke is to "be alert for sudden weakness or numbness." This is crucial because sudden weakness or numbness in the face, arm, or leg, especially on one side of the body, is one of the hallmark symptoms of a stroke. It is essential to recognize these signs promptly and seek immediate medical attention to minimize the potential damage caused by a stroke. Being aware of these sudden symptoms can help individuals receive timely treatment and improve their chances of recovery.

Correct Answer: A

Rationale: Cloudy urine following a kidney transplant may be a common occurrence and could be due to various factors such as dehydration, medication side effects, or the presence of mucus, cells, or proteins in the urine. The nurse should first record the finding and then further assess the patient by checking for other signs and symptoms like pain, fever, or abnormal odors in the urine. If the cloudy urine is persistent or accompanied by other concerning symptoms, then the nurse should notify the physician for further evaluation. However, initially recording the finding allows for documentation and monitoring of the patient's condition, providing a baseline for further assessment and intervention if necessary. It is important to remember that cloudy urine alone may not always indicate a serious issue, but thorough assessment and documentation are essential steps in ensuring the patient's well-being.

Correct Answer: A

Rationale: Palpation for skin turgor is used to assess the hydration status of a patient. Skin turgor is a measure of the skin's elasticity and hydration level. When a patient is well-hydrated, their skin will have good turgor, meaning it will return to its normal position quickly after being pinched. On the other hand, in a dehydrated patient, the skin will have poor turgor and will not return to its normal position promptly. Therefore, assessing skin turgor is a valuable tool for determining a patient's hydration status during a physical examination of the renal system. Palpation of both kidneys, auscultation of renal arteries, and percussion for dullness over the bladder are not specifically related to assessing hydration status.

Correct Answer: A

Rationale: For a client with coronary artery disease, physical rest is important to help decrease cardiac workload and sympathetic nervous system stimulation. Physical rest helps reduce the demand on the heart muscle, allowing the heart to work more efficiently. By minimizing physical activity, the client can prevent further strain on the heart and lower the risk of complications such as angina or heart attack. Additionally, reducing physical activity can help lower blood pressure and heart rate, which in turn decreases the workload on the heart. Thus, recommending physical rest is essential in managing and improving outcomes for clients with coronary artery disease.