Fundamental Concepts and Skills for Nursing 6th Edition Test Bank

Correct Answer: C

Rationale: Chvostek�s sign is an assessment technique used to detect hypocalcemia. The nurse will tap lightly over the facial nerve, just in front of the patient�s ear. A positive Chvostek�s sign is indicated by a twitching of the facial muscles on the same side of the face as the area that was tapped. This twitching is due to the hyperexcitability of the facial nerve, which can be a sign of low calcium levels. Therefore, option C is the correct way to conduct the assessment for Chvostek�s sign.

Correct Answer: B

Rationale: Ventricular fibrillation is the dysrhythmia most commonly associated with sudden cardiac death (SCD). Ventricular fibrillation is a rapid, chaotic, and disorganized electrical activity in the ventricles that leads to ineffective contraction. This dysrhythmia can quickly progress to hemodynamic collapse and ultimately cardiac arrest, resulting in sudden cardiac death if not promptly treated with defibrillation. Atrial flutter, paroxysmal supraventricular tachycardia, and junctional escape rhythm are not typically associated with as high a risk of sudden cardiac death as ventricular fibrillation.

Correct Answer: A

Rationale: Encouraging oral intake of fluids when permitted is the most appropriate intervention to support the pediatric client's fluid status post-surgery. Adequate hydration is essential for the recovery process, and oral intake of fluids helps maintain fluid balance. Limiting oral and intravenous intake of fluids (option B) would not be beneficial in promoting hydration and recovery. Continuing normal saline administration even after oral intake is normal (option C) may lead to fluid overload. Converting the intravenous line to a saline lock immediately after surgery (option D) may not be ideal as the client may still need intravenous fluids to support hydration until they can tolerate oral intake effectively.

Correct Answer: A

Rationale: Option A is the most appropriate response by the nurse because it provides accurate information related to the client's concern about developing coronary artery disease. Studies have shown that women who take oral contraceptives have an increased risk of developing cardiovascular issues, including coronary artery disease. By providing this information, the nurse addresses the client's statement and educates her about a potential risk factor for the disease. This empowers the client with knowledge that can help her understand the possible reasons behind her diagnosis and make informed decisions about her health moving forward.

Correct Answer: B

Rationale: In disseminated intravascular coagulation (DIC), the client experiences widespread clotting throughout the body's small blood vessels, leading to organ damage and bleeding. Maintaining skin integrity is a priority intervention because DIC can cause hemorrhage and increased risk of skin breakdown due to impaired blood circulation. Preventing pressure ulcers and promoting skin health in a client with DIC is crucial to prevent further complications. Frequent ambulation may not be safe for a client with DIC due to the risk of bleeding from compromised blood vessels. Preparation for radiograph procedures and fluid restriction may be necessary interventions depending on the client's condition, but they are not the priority in the immediate care of a client with DIC.