Fundamental Concepts and Skills for Nursing Test Bank

Correct Answer: D

Rationale: The statement "My doctor told me I have a slight amount of protein in my urine" suggests that the patient has proteinuria, which is a condition where abnormal amounts of protein are found in the urine. Proteinuria can be an indication of a health problem affecting the renal system, such as kidney disease or dysfunction. This made the nurse suspect that the older female patient may have an issue with her renal system. Statements A, B, and C are common experiences related to urinary habits but do not specifically point towards a renal health problem like proteinuria does.

Correct Answer: A

Rationale: A. Dementia causes impaired short- and long-term memory: Impaired memory is a common symptom of dementia, affecting both short-term and long-term memory. Patients may struggle to remember recent events or past memories, which can significantly impact their daily functioning.

Correct Answer: D

Rationale: The nurse should emphasize the use of ice after a sprained ankle because it helps decrease the diameter of blood vessels. By applying ice to the injured area, vasoconstriction occurs, which means the blood vessels constrict and become narrower. This helps reduce swelling, inflammation, and pain associated with the injury. Cold therapy through the application of ice is a common approach used in the immediate management of sprains and strains to promote healing and alleviate discomfort.

Correct Answer: C

Rationale: For an older patient with heart failure prescribed digoxin (Lanoxin) 125 mcg by mouth three times a week, the nurse should administer the drug as prescribed while monitoring for manifestations of toxicity. Digoxin is a medication commonly used in heart failure, but it has a narrow therapeutic index, meaning that the difference between a therapeutic dose and a toxic dose is small. Older patients are more susceptible to digoxin toxicity due to age-related changes in pharmacokinetics and pharmacodynamics, as well as potential comorbidities. Therefore, close monitoring for signs and symptoms of digoxin toxicity, such as nausea, vomiting, visual disturbances, and cardiac arrhythmias, is essential. It is important for the nurse to be vigilant for any early signs of toxicity and communicate any concerns to the healthcare provider promptly.

Correct Answer: B

Rationale: Atorvastatin (Lipitor) is a medication commonly used to treat high cholesterol levels. One of the serious side effects associated with atorvastatin use is muscle pain and weakness. This could be a sign of a rare but serious condition known as rhabdomyolysis, which is the breakdown of muscle tissue that can lead to kidney damage. Therefore, it is crucial for the client to report any muscle pain or weakness promptly to their healthcare provider to prevent any serious complications. Headaches and nausea are common side effects that may not require urgent attention. Bruising and excessive bleeding usually indicate a different issue, such as a bleeding disorder or anticoagulant medication effect. Shortness of breath and coughing are not typically associated with atorvastatin use and may suggest other health problems that require evaluation by a healthcare provider.