Medical Surgical Nursing Concepts and Practice Test Bank

Correct Answer: A

Rationale: The most common clinical manifestation of coronary artery disease is chest pain, also known as angina pectoris. This pain is typically described as a pressure, squeezing, tightness, or heaviness in the chest that may radiate to the arms, neck, jaw, shoulders, or back. It is usually triggered by physical exertion or emotional stress and is relieved by rest or medications such as nitroglycerin. Chest pain occurs due to reduced blood flow to the heart muscles caused by atherosclerosis in the coronary arteries. While dyspnea (shortness of breath), irritability, and tachycardia (rapid heart rate) can also be associated with coronary artery disease, chest pain is the hallmark symptom that often prompts individuals to seek medical attention for further evaluation.

Correct Answer: C

Rationale: For a patient experiencing end-stage renal disease, it is important for the nurse to discuss the advantages and disadvantages of different renal replacement therapies. This goal is crucial to help the patient make informed decisions about their treatment options. Patients with end-stage renal disease often face choices between hemodialysis, peritoneal dialysis, and kidney transplantation. Understanding the advantages and disadvantages of each therapy can empower the patient to actively participate in their treatment decision-making process and achieve the best possible outcomes for their health. It is essential for the nurse to promote patient education and shared decision-making to ensure that the patient's preferences and values are respected throughout their care journey.

Correct Answer: D

Rationale: Phantom limb sensation is a common phenomenon where a patient perceives sensations such as cramping, itching, or pain in the limb that has been amputated. This occurs because the brain continues to receive signals from the nerves that originally innervated the amputated limb, leading to the perception of sensation in the absent body part. In this case, the patient's complaint of toes cramping in the amputated foot is indicative of phantom limb sensation rather than contractures, attention-seeking behavior, or chronic stump pain. It is important for the nurse to educate the patient about this phenomenon and provide appropriate support and reassurance.

Correct Answer: D

Rationale: Disseminated intravascular coagulation (DIC) is a serious condition characterized by both excessive clotting and bleeding throughout the body. The primary goal of care for a client with DIC is to manage and balance the clotting and bleeding tendencies. A key indicator of successful care for a client with DIC is the absence of bleeding, as this suggests that the coagulation process has been stabilized and there is no ongoing clot breakdown leading to bleeding. Monitoring for signs of bleeding, such as petechiae, purpura, ecchymosis, hematuria, and gastrointestinal bleeding, is essential in evaluating the effectiveness of care in a client with DIC. Therefore, the absence of bleeding is the most significant finding that indicates successful care in a client with DIC.

Correct Answer: A

Rationale: Patients with hypothyroidism often exhibit rough, dry skin as a result of decreased thyroid hormone levels impacting the skin's ability to retain moisture. This condition, known as myxedema, can lead to skin changes such as dryness, scaling, and thickening. The skin may also appear pale or yellowish due to reduced blood flow. Therefore, the nurse should expect the patient with newly diagnosed hypothyroidism to present with rough, dry skin during assessment.