Medical Surgical Nursing Concepts and Practice Test Bank -Nurselytic

Correct Answer: B

Rationale: The client who is postoperative from a major surgery, such as femur fracture repair, is at the highest risk for a nonthrombotic pulmonary embolism (PE). Postoperative clients are at an increased risk due to factors such as immobility, surgical trauma, and possible venous stasis. Additionally, major orthopedic surgeries involving the lower extremities carry a higher risk of developing a PE because of the potential for blood clots to form in the veins of the legs (deep vein thrombosis) and then travel to the lungs, leading to a pulmonary embolism. Close monitoring and preventative measures, such as early ambulation, compression devices, and anticoagulant therapy, are crucial in preventing this serious complication in postoperative clients.

Correct Answer: B

Rationale: In eclampsia, seizures can occur due to the underlying hypertensive crisis affecting the brain. A classic grand mal seizure consists of two phases: the tonic phase and the clonic phase. During the tonic phase, there is a sudden loss of consciousness and muscle tone, leading to the person falling down. The clonic phase follows the tonic phase and is characterized by rhythmic, repetitive muscle contractions and relaxation.
Therefore, the accurate statement about the characteristics of a grand mal seizure in the context of eclampsia is that the clonic phase is evidenced by muscular contraction and rigidity.

Correct Answer: A

Rationale: A transient ischemic attack (TI
A) 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: 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: In a pregnant woman, a hematocrit level of 24% is cause for concern as it is lower than the normal range during pregnancy. A lower than normal hematocrit level may indicate anemia in the pregnant woman, which can lead to complications for both the mother and the baby. Anemia during pregnancy can result in inadequate oxygen reaching the tissues, fatigue, increased risk of preterm birth, and low birth weight for the baby.
Therefore, this finding should be further evaluated and managed promptly to ensure the well-being of the pregnant woman and her baby.