A baby will be having surgery to correct a congenital heart defect. On which topic should the parents be instructed regarding the care of the child before surgery?

Correct Answer: B

Rationale: It is crucial for parents to be instructed on preventing exposure to infection before their baby's surgery to correct a congenital heart defect. Infections can pose a serious risk to individuals, especially those with preexisting medical conditions like a congenital heart defect. Infection control measures, such as handwashing, avoiding sick contacts, and keeping the environment clean, can help reduce the risk of postoperative complications due to infections. This instruction is important to help ensure the successful outcome of the baby's surgery and recovery process. It is essential for parents to be vigilant in maintaining a hygienic environment and taking necessary precautions to prevent their baby from getting sick prior to the surgery.

Correct Answer: C

Rationale: Bladder cancer is a health problem that can result from a combination of genetic and environmental factors. Genetic mutations can predispose individuals to developing bladder cancer, while environmental factors such as smoking, exposure to certain chemicals, and chronic bladder irritation can also contribute to the development of the disease. Hematuria (blood in the urine) can be a symptom of bladder cancer, but it is not specific to this type of cancer and can also occur in other renal system disorders. Incontinence and kidney infections are not typically associated with genetic predisposition as much as bladder cancer.

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.

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: 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: 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: 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: 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: 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.