Concepts for Nursing Practice Giddens Test Bank

Correct Answer: A

Rationale: A neurovascular assessment is performed to evaluate nerve function, circulation, and tissue perfusion. Pale, cold fingers indicate poor circulation, which can be a sign of compromised blood flow from the cast causing decreased oxygen supply to the tissues. This finding is concerning as it suggests potential nerve or vascular compromise, which could lead to serious complications if not addressed promptly. It is important for the nurse to report this finding to the healthcare provider for further evaluation and intervention.

Correct Answer: C

Rationale: Progressive shock leads to a mismatch between oxygen demand and supply, causing a shift from aerobic to anaerobic metabolism in cells. As oxygen delivery decreases due to factors such as decreased blood volume or cardiac output, cells are unable to meet their energy needs through aerobic metabolism. This results in the conversion of pyruvate to lactate through anaerobic glycolysis, leading to lactic acidosis and further cellular dysfunction. Recognizing this shift in metabolism is crucial for the nurse to intervene promptly to restore tissue perfusion and prevent further organ damage in the client in hemorrhagic shock.

Correct Answer: D

Rationale: Torsades de Pointes is a specific type of ventricular tachycardia characterized by a distinctive twisting pattern on an ECG. It is often associated with a prolonged QT interval and can potentially lead to a life-threatening arrhythmia known as ventricular fibrillation. Sinus tachycardia, atrial flutter, and junctional escape rhythms are not forms of ventricular tachycardia.

Correct Answer: D

Rationale: Obesity is a significant risk factor for the development of preeclampsia in pregnancy. Preeclampsia is characterized by high blood pressure and signs of damage to other organ systems, typically after 20 weeks of pregnancy. Obesity can lead to increased inflammation and affect the function of blood vessels, which can contribute to the development of preeclampsia. It is essential for the nurse to recognize obesity as a risk factor in this scenario to provide appropriate monitoring and interventions to ensure the health and safety of both the client and the baby.

Correct Answer: A

Rationale: The correct answer is that the younger client will need more frequent monitoring than the older client. This is because age can influence how the body processes medications, including anticoagulants. While older adults may require lower dosages due to changes in metabolism and potential increased sensitivity to medications, they may still require less monitoring than younger individuals. The younger client may need more frequent monitoring to ensure the anticoagulant is being effective and not causing any adverse effects, given variations in metabolism and potential multi-drug interactions. Age is just one factor to consider when individualizing care for clients on anticoagulant therapy, and close monitoring is essential for both age groups.