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The nurse is concerned that a client admitted for a total hip replacement is at risk for thrombus formation. Which assessment finding caused the nurse to draw this conclusion?
- A. Body mass index (BMI) 35.8
- B. Former cigarette smoker
- C. Blood pressure 132/88 mmHg
- D. Age 45 years
Correct Answer: B
Rationale: A former cigarette smoker is at increased risk for thrombus formation due to the damage smoking causes to the blood vessels, increasing the likelihood of blood clots. Smoking can also contribute to inflammation and increased platelet activation, further promoting clot formation. This risk factor is particularly concerning in a client undergoing a total hip replacement surgery, as immobility and surgery itself can also increase the risk of blood clots forming. Monitoring and addressing this risk factor is important in preventing potential complications such as deep vein thrombosis or pulmonary embolism in this client population. While the other assessment findings are important to consider for overall health, the former cigarette smoking status is specifically associated with thrombus formation in this scenario.
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The nurse is assessing a client who is in the third trimester of pregnancy. Which finding would require immediate intervention by the nurse?
- A. Blood pressure of 142/92 mmHg
- B. Pulse of 92 beats per minute
- C. Respiratory rate of 24 per minute
- D. Weight gain of 16 oz per week
Correct Answer: A
Rationale: A blood pressure of 142/92 mmHg in a client in the third trimester of pregnancy is elevated and could indicate the development of preeclampsia, a serious hypertensive disorder that can have adverse effects on both the mother and the fetus. Preeclampsia is characterized by high blood pressure accompanied by signs of organ damage, such as proteinuria and changes in other laboratory values. Immediate intervention is required in this situation, as preeclampsia can lead to complications such as seizures (eclampsia), stroke, and placental abruption. It is essential for the nurse to further assess the client and notify the healthcare provider promptly for appropriate management.
After being diagnosed with polycystic kidney disease, an adult patient asks if current children are at risk for developing the disorder. How should the nurse respond?
- A. The adult form of this disorder is rare and should not affect grown children
- B. The children should undergo genetic testing and screening for evidence of the disease
- C. Because the condition was just diagnosed, there is no risk of passing the condition on to any children
- D. The children would have developed symptoms of the disorder in utero or shortly after birth if they had inherited the defective gene
Correct Answer: B
Rationale: Polycystic kidney disease (PKD) is a genetic disorder that can be inherited by children if one or both parents have the gene mutation responsible for the condition. In cases where a parent has been diagnosed with PKD, their children are at risk of inheriting the faulty gene. As such, it is recommended for the children to undergo genetic testing and screening to identify any evidence of the disease early on. By identifying the gene mutation in the children, appropriate monitoring and management can be initiated, potentially leading to better outcomes and quality of life for the affected individuals. Therefore, genetic testing and screening are crucial in cases where there is a known genetic component to a disorder like PKD.
The nurse is caring for a client admitted to the hospital with lower extremity edema and shortness of breath. Which electrocardiogram finding indicates the client is at risk for an alteration in perfusion?
- A. P wave smooth and round
- B. Absent U wave
- C. PR interval 0.30 seconds
- D. ST segment isoelectric
Correct Answer: D
Rationale: An isoelectric ST segment on an electrocardiogram can indicate myocardial ischemia or injury, which can lead to a decrease in perfusion to the heart muscle. This finding suggests an increased risk of inadequate blood flow to the heart, potentially resulting in further complications such as a myocardial infarction or altered perfusion to other organs. In a client with lower extremity edema and shortness of breath, identifying this ECG finding is crucial for early intervention and monitoring to prevent further deterioration in perfusion status.
The nurse has a 7-year-old client recovering from partial-thickness burns to the arms and hands. This client has shown sensitivity to loud noises and bright lights, and at times if she is overstimulated she won't speak to or look at anyone but her parents until she calms down. The nurse considers the best teaching environment for this client to be the
- A. client's room.
- B. pediatric ward waiting area.
- C. hospital cafeteria.
- D. pediatric ward play area.
Correct Answer: A
Rationale: For a 7-year-old client recovering from partial-thickness burns with sensitivity to loud noises and bright lights, along with a tendency to become overstimulated, the best teaching environment would be the client's room. This setting provides a familiar and comforting space where the client feels secure and less exposed to external stimuli that may trigger discomfort or anxiety. Being in her own room allows the client to focus better, feel more at ease, and have better communication with the nurse without distractions from bright lights, loud noises, or other people around. This controlled and peaceful environment contributes to a more effective teaching and learning experience for the client, promoting better understanding and retention of information.
The nurse is providing care to a client who has experienced several episodes of angina. Which agent does the nurse anticipate being ordered to reduce the intensity and frequency of an angina episode?
- A. The client will experience relief of chest pain with therapeutic lifestyle changes.
- B. The client will experience relief of chest pain with statin therapy.
- C. The client will experience relief of chest pain with nitrate therapy.
- D. The client will experience relief of chest pain with anticoagulant therapy.
Correct Answer: C
Rationale: Nitrates are commonly prescribed for the management of angina. These agents work by dilating blood vessels, which leads to improved blood flow to the heart muscle and decreased workload on the heart. This results in reduced intensity and frequency of angina episodes by increasing oxygen supply to the heart and decreasing its demand. Nitrates can be administered sublingually, orally, or topically to provide prompt relief of chest pain during an angina episode. Thorough patient education should be provided regarding the proper use of nitrates and potential side effects.