Fundamental Concepts and Skills for Nursing 6th Edition Test Bank

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: 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: D

Rationale: Breaking the information into small sessions to enhance learning is the most effective approach when organizing the teaching experience for a client with a new permanent colostomy. This allows for better retention of information as the client can focus on a few key points at a time and then progressively build upon that knowledge. By breaking the information into smaller sessions, the nurse can ensure that the client fully understands each aspect of colostomy care before moving on to the next topic. This method promotes better understanding, leads to improved compliance with care instructions, and ultimately contributes to better outcomes for the client.

Correct Answer: C

Rationale: In stage III of heart failure, the client displays symptoms such as dyspnea, fatigue, and other symptoms with ordinary physical activity, known as NYHA Class III. This is consistent with the client's presentation of dyspnea with activities of daily living, indicating a moderate level of heart failure. The need for the placement of an implantable defibrillator also suggests a more advanced stage of heart failure compared to stage I or II. Stage IV is characterized by severe symptoms at rest, which the client does not exhibit based on the information provided.

Correct Answer: B

Rationale: The correct answer is B. The statement "I need to use a soft toothbrush and an electric razor to avoid injuries" indicates that the client understands the importance of preventive measures to minimize bleeding risks while on anticoagulant therapy. Using a soft toothbrush and an electric razor can help prevent accidental cuts that may lead to bleeding complications. It shows the client's understanding of the need to take precautions to avoid potential harm while on long-term anticoagulant therapy. The other statements do not directly address safety measures to prevent bleeding complications associated with anticoagulant therapy.