A client with disseminated intravascular coagulation (DIC) has a nursing diagnosis of Ineffective Peripheral Tissue Perfusion. Which actions interventions are appropriate for this diagnosis? Select all that apply.

Questions 15

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Fundamental Concepts and Skills for Nursing Test Questions Questions

Question 1 of 9

A client with disseminated intravascular coagulation (DIC) has a nursing diagnosis of Ineffective Peripheral Tissue Perfusion. Which actions interventions are appropriate for this diagnosis? Select all that apply.

Correct Answer: B

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

Question 2 of 9

A nurse is caring for a pregnant client who is hypertensive. Which additional clinical manifestations leads the nurse to believe that the client is experiencing early preeclampsia?

Correct Answer: D

Rationale: Early preeclampsia is a condition characterized by high blood pressure and signs of damage to another organ system, commonly the liver and kidneys. Severe epigastric pain is a common symptom of this organ involvement. It is caused by liver distention due to the breakdown of red blood cells and platelets, which can lead to a condition known as HELLP syndrome. This manifestation is a significant indicator of early preeclampsia and requires prompt evaluation and intervention to prevent complications for both the mother and the baby. While the other options may be present in preeclampsia, severe epigastric pain is a more specific and concerning symptom requiring immediate attention.

Question 3 of 9

A client with disseminated intravascular coagulation (DIC) has a nursing diagnosis of Ineffective Peripheral Tissue Perfusion. Which actions interventions are appropriate for this diagnosis? Select all that apply.

Correct Answer: B

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

Question 4 of 9

A patient admitted with possible kidney stones suddenly experiences acute crampy pain on the left side that radiates into the groin. The patient is nauseated, vomits clear fluid, and voids pink urine. What should the nurse do first?

Correct Answer: B

Rationale: The patient's symptoms are indicative of kidney stones causing obstruction and possibly renal colic. The sudden onset of severe crampy pain on the left side radiating into the groin, along with nausea, vomiting clear fluid, and passing pink urine (hematuria) are classic signs of kidney stones. Given the severity of the symptoms and the potential for complications, it is crucial to notify the physician immediately for further evaluation and management. Straining all urine, administering analgesics, and obtaining a bladder scan may be necessary interventions but should be done after informing the physician and following their recommendations.

Question 5 of 9

The nurse is caring for an infant diagnosed with hypoplastic left heart syndrome. The client has recently been scheduled for surgery to repair the defect. Which procedure does the nurse anticipate needing to provide client teaching about to the client's family?

Correct Answer: A

Rationale: The Norwood procedure is a surgical technique used to treat hypoplastic left heart syndrome, a congenital heart defect where the left side of the heart is underdeveloped. In this procedure, the surgeon creates a new functional aorta and reconstructs the right ventricle to take over pumping blood to both the lungs and the body. This procedure is typically performed in 3 stages, with the first stage usually done in the first week of life. Providing client teaching about the Norwood procedure is important for the family to understand the surgery, postoperative care, and potential complications. It helps prepare them for what to expect and how to best support their infant through the surgical and recovery process.

Question 6 of 9

The nurse is caring for a breastfeeding client recovering from a cesarean section. The physician diagnoses her with superficial venous thrombosis. Which intervention should the nurse anticipate carrying out first?

Correct Answer: C

Rationale: Superficial venous thrombosis is a condition characterized by the formation of a blood clot in a superficial vein. The initial intervention for this condition is to apply warm, moist compresses to the affected area. The warmth can help to increase blood flow and promote the resolution of the clot. It also helps to reduce pain and inflammation in the area. Encouraging ambulation, taking aspirin, or administering methylergonovine are not appropriate interventions for superficial venous thrombosis and could potentially worsen the condition or lead to complications.

Question 7 of 9

The nurse is caring for a client with hypertension. Which diagnostic tests should the nurse anticipate being ordered to rule out secondary causes? Select all that apply.

Correct Answer: A

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

Question 8 of 9

A client with a suspected transient ischemic attack (TIA) presents to the emergency department with aphasia. Based on this data, the nurse plans care based on ischemia to which portion of the brain?

Correct Answer: C

Rationale: Aphasia, which is the inability to understand or express speech, is typically associated with damage to the left hemisphere of the brain. In a client with suspected transient ischemic attack (TIA) presenting with aphasia, the nurse would plan care based on ischemia affecting the left hemisphere of the brain. The left hemisphere is responsible for language processing in most individuals, so damage in this area can result in communication deficits such as aphasia.

Question 9 of 9

The nurse is conducting a class for a group of pregnant clients and wants to focus specifically on the risks of alcohol consumption for the developing fetus. Which topic should the nurse include with regard to safety of the fetus?

Correct Answer: A

Rationale: Understanding human growth and development is crucial when discussing the risks of alcohol consumption for the developing fetus. Alcohol can have profound negative effects on the developing fetus, leading to a range of physical, cognitive, and behavioral abnormalities known as Fetal Alcohol Spectrum Disorders (FASDs). These effects can impact the fetus at various stages of development, making it important for pregnant clients to be aware of the risks associated with alcohol consumption during pregnancy. By focusing on human growth and development, the nurse can help pregnant clients grasp the critical importance of avoiding alcohol to ensure the healthy growth and development of their babies.

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