Concepts for Nursing Practice Giddens Test Bank

Correct Answer: B

Rationale: - Compression stockings help promote blood circulation in the legs, decreasing the risk of blood clots forming. This is important after surgery, especially in older adults who may have a higher risk.

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: 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: A

Rationale: The nurse would suspect that the client may be unable to read the instructions because the client mentioned needing glasses to read them later. Additionally, the client also stated that everything they need to know has already been told to them by the nurse, indicating potential difficulty with reading or understanding written instructions. It would be important for the nurse to explore further and provide alternative methods of communication or support to ensure the client receives and comprehends the necessary information for postoperative care.