Medical Surgical Nursing Concepts and Practice Test Bank

Correct Answer: A

Rationale: A transient ischemic attack (TIA) is often considered a warning sign that the individual is at an increased risk for a future ischemic stroke. TIAs are brief episodes of neurological dysfunction caused by a temporary disruption in blood supply to the brain. While the symptoms of a TIA typically resolve within 24 hours, they should not be ignored as they indicate an underlying vascular issue that needs to be addressed to prevent a more severe stroke in the future. Therefore, the client is at risk for an ischemic thrombotic stroke and should receive appropriate interventions and follow-up care to manage this risk.

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.

Correct Answer: A

Rationale: The statement "Nicotine causes vasospasms, which reduce blood flow to the legs" is the most appropriate response when discussing risk factors for PVD with a client who is obese, has a history of smoking, and works as a contractor. Nicotine in cigarette smoke can lead to constriction or narrowing of blood vessels, including those in the legs, which can reduce blood flow to the lower extremities. This can contribute to the development and progression of peripheral vascular disease (PVD) in individuals with a history of smoking. Identifying and educating the client about this specific risk factor related to their smoking history is important in managing their condition and preventing further complications.

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.