Concept Based Nursing Practice Questions

Correct Answer: C

Rationale: The correct statement indicating effective discharge teaching for a client diagnosed with cardiomyopathy is "I will eat foods containing sodium only if drinking water with them." This statement shows the client understands the importance of reducing sodium intake to manage cardiomyopathy effectively. Excess sodium can contribute to fluid retention and worsen symptoms of heart failure, which often accompanies cardiomyopathy. By pairing sodium-containing foods with water, the client can help mitigate the potential negative effects of sodium on their condition. The other options are incorrect as they do not demonstrate an understanding of the condition or appropriate self-care measures.

Correct Answer: C

Rationale: The correct action for the nurse in this situation would be to ensure the client is evaluated by his/her medical provider. Chest fluttering, also known as palpitations, can sometimes be related to cardiac arrhythmias, which can be a concern in older adults. Even though the client reports no other symptoms and the frequency is intermittent, it is essential for the medical provider to assess and determine the cause of the fluttering to rule out any serious underlying cardiac issues. Taking appropriate action promptly can help prevent any potential complications and ensure the client's well-being.

Correct Answer: B

Rationale: The correct statement that should be included in the presentation is that African Americans have almost twice the number of first-ever strokes compared with Whites. This is based on research and statistics that show African Americans have a higher incidence of stroke compared to other ethnic groups in the United States. It is important for healthcare providers to be aware of these disparities in order to address them effectively through targeted prevention and management strategies. Moreover, raising awareness about these risk factors can help promote early intervention and reduce the burden of stroke within the African American community.

Correct Answer: C

Rationale: In a client with deep venous thrombosis (DVT), the priority problem would be peripheral perfusion. DVT is a condition where a blood clot forms in a vein deep within the body, usually in the lower extremities. This clot can impede blood flow in the affected vein, leading to compromised circulation to the surrounding tissues. Poor peripheral perfusion can result in tissue ischemia and potential tissue necrosis. Monitoring and ensuring adequate peripheral perfusion is crucial to prevent tissue damage and further complications such as pulmonary embolism. Therefore, addressing and improving peripheral perfusion would be the priority in caring for a client with DVT.

Correct Answer: B

Rationale: Monitoring the client's oxygen saturation intermittently is the most appropriate action when providing care for a client with disseminated intravascular coagulation (DIC) who has a nursing diagnosis of Impaired Gas Exchange. DIC can lead to a variety of complications, including inadequate oxygenation of tissues due to abnormal clotting and bleeding. By monitoring the client's oxygen saturation levels, the healthcare team can assess the effectiveness of gas exchange and adjust interventions as needed to optimize oxygenation. This action helps in early detection of worsening gas exchange and guides appropriate interventions to address any respiratory issues promptly. Placing the client in a low-Fowler position may not be suitable for all patients with DIC, encouraging frequent ambulation could be risky due to the increased bleeding tendency, and using continuous endotracheal suctioning is not recommended as it can lead to aggravation of respiratory issues and increase the risk of further complications.