Nursing a Concept Based Approach to Learning Test Bank

Questions 14

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Nursing a Concept Based Approach to Learning Test Bank Questions

Question 1 of 5

The nurse is planning care for a client with peripheral vascular disease (PVD) who is at risk for Impaired Skin Integrity. Which intervention is appropriate for the nurse to include in the plan of care?

Correct Answer: B

Rationale: For a client with peripheral vascular disease (PVD) who is at risk for Impaired Skin Integrity, keeping the skin clean and dry, and moisturizing areas of dryness is crucial. Patients with PVD often have compromised circulation to the extremities, which can lead to decreased oxygen and nutrient delivery to tissues, increasing the risk of skin breakdown and impaired wound healing. Proper skin care helps prevent skin breakdown, decreases the risk of infection, and promotes overall skin health. Keeping the skin clean and dry helps prevent skin breakdown, while moisturizing areas of dryness helps maintain skin integrity. This intervention focuses on maintaining skin health and preventing complications associated with compromised circulation in patients with PVD.

Question 2 of 5

A pregnant client is diagnosed with HELLP syndrome. Based on this diagnosis, which laboratory findings are consistent with diagnosis of HELLP?

Correct Answer: B

Rationale: HELLP syndrome is a serious complication of pregnancy characterized by Hemolysis (H), Elevated Liver enzymes (EL), and a Low Platelet count (LP). Therefore, the correct laboratory finding consistent with the diagnosis of HELLP syndrome is hemolysis. This can be indicated by an elevated lactate dehydrogenase (LDH) level, low haptoglobin, elevated bilirubin, and the presence of schistocytes on a blood smear. The other options (A, C, and D) do not align with the classic presentation of HELLP syndrome.

Question 3 of 5

The nurse is planning care for a newly admitted client diagnosed with pulmonary embolism (PE). The nurse anticipates the client will need anticoagulant therapy. What is true regarding this therapy for the treatment of this condition?

Correct Answer: D

Rationale: Anticoagulant therapy, specifically heparin, is commonly used as the initial treatment for pulmonary embolism (PE) because it inhibits the formation of additional clots by altering the synthesis of vitamin K-dependent clotting factors. Heparin works quickly and can be administered intravenously to rapidly prevent the clot from growing in size. Warfarin, another anticoagulant, is generally started after heparin therapy is initiated to provide long-term anticoagulation. Major hemorrhage is a potential side effect of anticoagulant therapy, but it is not considered common. The initiation of heparin and warfarin (Coumadin) at the same time is not standard practice due to the differing mechanisms of action and monitoring required for each medication. Anticoagulant therapy is considered first-line treatment for PE, not second-line.

Question 4 of 5

The nurse is caring for a patient with an epiphyseal fracture. What bone classification should the nurse keep in mind when planning this patient�s care?

Correct Answer: B

Rationale: An epiphyseal fracture involves the distal or proximal epiphysis of a long bone, such as the femur, tibia, or humerus. Long bones are characterized by having a long shaft with distinct ends (epiphyses). The epiphysis is the site of bone growth and plays a crucial role in bone development. Therefore, understanding the classification of the bone as long helps the nurse in providing appropriate care for the patient with an epiphyseal fracture, such as monitoring growth plate involvement and ensuring proper immobilization for healing.

Question 5 of 5

The nurse is planning care for a client admitted with a stroke. Which intervention would support the client's sensorimotor needs?

Correct Answer: A

Rationale: Supporting a stroke client's sensorimotor needs involves encouraging independence and rehabilitation of the affected side. By encouraging the use of the nonaffected arm for self-care activities like feeding, bathing, and dressing, the nurse is promoting sensorimotor development and function in the affected arm. This intervention will help the client regain strength, coordination, and functionality in the affected arm, which is crucial for their overall recovery and independence. Encouraging the client to actively engage the affected arm promotes neuroplasticity and can improve motor function over time.

Similar Questions

The nurse is planning care for a client admitted with a stroke. Which intervention would support the client's sensorimotor needs?
The nurse is planning care for a client with peripheral vascular disease (PVD) who is at risk for Impaired Skin Integrity. Which intervention is appropriate for the nurse to include in the plan of care?
The nurse is caring for a 76-year-old client with a history of angina. What atypical age- related warning sign of a myocardial infarction should the nurse need to include in client teaching?
The nurse is caring for a client who has not been adhering to treatment with anti-hypertension medication. Which approach to addressing this issue should the nurse use?
A client with disseminated intravascular coagulation (DIC) is experiencing joint pain. Which nursing intervention is appropriate for this client?

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