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: An increased amount of glucocorticoids being released can lead to an inhibition of the immune response. Glucocorticoids have anti-inflammatory effects and suppress the immune system, which can make the patient more susceptible to infections and impair the body's ability to fight off pathogens. This can manifest as an increased risk of infections and slower wound healing in the patient with adrenal cortex dysfunction. The other options, such as delayed onset of puberty, decreased metabolic rate, and increased response to glucagon, are not directly related to the effects of increased glucocorticoids on the immune response.

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: Although physical activity restrictions are commonly recommended for younger clients with hypertrophic cardiomyopathy (HCM) to reduce the risk of sudden cardiac death, this may not be the best option for a 72-year-old client. Older adults can still benefit from regular physical activity to maintain overall health and mobility. It is important to individualize the exercise recommendations based on the client's overall health status, functional capacity, and specific considerations related to their condition. In this case, the healthcare team would likely focus on other treatment options such as beta-blocker or calcium channel blocker administration, and consider the potential benefits of defibrillator implantation for the older client with HCM.

Correct Answer: D

Rationale: Creatinine clearance is a diagnostic test that helps determine both the glomerular filtration rate (GFR) and the extent of glomerular damage in the renal system. Creatinine is a waste product produced by muscles and excreted by the kidneys. A decrease in the glomerular filtration rate indicates impaired kidney function, which could be due to glomerular damage or other renal issues. By measuring the amount of creatinine in the blood and urine over a specific period of time, creatinine clearance provides an estimate of the GFR. This test is commonly used to assess kidney function in patients with renal disease or renal impairment.