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A 20-year-old diagnosed with appendicitis is being assessed by the nurse. Which statement by the client will make the nurse intervene immediately?
- A. I have no appetite.
- B. The pain hurts so much it is making me nauseous.
- C. When I position myself on my right side, it makes the pain worse.
- D. The pain seems to be gone now.
Correct Answer: D
Rationale: The correct answer is D because sudden relief of pain in appendicitis could indicate a ruptured appendix, which is a surgical emergency requiring immediate intervention. This is because when the appendix ruptures, the pain initially decreases due to the release of pressure in the appendix, but the situation can quickly escalate to a life-threatening condition like peritonitis. Choices A, B, and C all indicate ongoing symptoms of appendicitis that would warrant further assessment and intervention.
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A nurse is caring for a client. Select the 5 findings that can cause delayed wound healing.
- A. Prealbumin level.
- B. History of diabetes mellitus.
- C. History of hyperlipidemia.
- D. Wound infection.
- E. Decreased pedal perfusion.
- F. Fasting blood glucose.
Correct Answer: A,B,D,E,F
Rationale: The correct findings that can cause delayed wound healing are A, B, D, E, and F.
A: Prealbumin level reflects protein status, crucial for wound healing.
B: Diabetes mellitus impairs wound healing due to poor circulation and high blood sugar.
D: Wound infection delays healing by increasing inflammation and preventing tissue repair.
E: Decreased pedal perfusion reduces blood flow to the wound site, hindering healing.
F: Fasting blood glucose levels affect the body's ability to heal due to impaired immune function and reduced collagen formation.
Incorrect choices: C - Hyperlipidemia does not directly impact wound healing; G - Insufficient information provided.
A nurse is teaching a class about preventive care to clients who are at risk for acquiring viral hepatitis. Which of the following information should the nurse include in the presentation?
- A. Avoid handwashing after eating.
- B. Avoid foods prepared with tap water.
- C. Avoid eating meat.
- D. Avoid covering sores with bandages.
Correct Answer: B
Rationale: The correct answer is B: Avoid foods prepared with tap water. This is important because tap water in certain regions may be contaminated with hepatitis-causing viruses. Avoiding tap water in food preparation reduces the risk of contracting viral hepatitis. Handwashing after eating (A) is actually recommended for preventing the spread of infections. Avoiding eating meat (C) is not necessary for preventing viral hepatitis transmission. Covering sores with bandages (D) is unrelated to the prevention of viral hepatitis.
A client with a diagnosis of valvular heart disease is being considered for mechanical valve replacement. Which circumstance is essential to assess before the surgery is performed?
- A. The ability to comply with anticoagulant therapy for life.
- B. The likelihood of the client experiencing body image problems.
- C. The physical demands of the client’s lifestyle.
- D. The ability to participate in a cardiac rehabilitation program.
Correct Answer: A
Rationale: The correct answer is A: The ability to comply with anticoagulant therapy for life. This is essential because mechanical valve replacement requires lifelong anticoagulant therapy to prevent clot formation. Noncompliance can lead to serious complications such as thromboembolism or valve failure. Assessing the client's understanding, willingness, and ability to adhere to this therapy is crucial for successful outcomes.
Other options are incorrect because:
B: Body image problems are important but not essential before surgery.
C: Physical demands of lifestyle are relevant but not crucial for valve replacement.
D: Participation in cardiac rehab is beneficial post-surgery but not essential before.
Overall, the ability to comply with anticoagulant therapy is the most critical factor to assess preoperatively.
A nurse in an emergency department is caring for a client who has burns on the front and back of both arms. Using the rule of nines, the nurse should document burns to which percentage of the client’s total body surface area (TBSA)?
- A. 9 percent.
- B. 18 percent.
- C. 36 percent.
- D. 54 percent.
Correct Answer: B
Rationale: The correct answer is B (18 percent). The rule of nines is used to estimate the percentage of total body surface area (TBSA) affected by burns. According to this rule, each arm represents 9% of the TBSA (9% front + 9% back = 18%). Therefore, burns on both front and back of both arms would total 18% TBSA. Choices A, C, and D are incorrect because they do not accurately reflect the TBSA affected by burns on both arms. Choice A (9 percent) represents the TBSA of one arm, not both. Choices C (36 percent) and D (54 percent) overestimate the TBSA since they do not consider the rule of nines for the arms.
A nurse is caring for a client who has heart failure and is experiencing atrial fibrillation. Which of the following findings should the nurse plan to monitor for and report to the provider immediately?
- A. Irregular pulse.
- B. Persistent fatigue.
- C. Dependent edema.
- D. Slurred speech.
Correct Answer: D
Rationale: The correct answer is D: Slurred speech. Slurred speech can be a sign of a potential stroke, which can occur in patients with atrial fibrillation due to the risk of blood clots forming in the heart. This finding should be reported immediately to the provider for further evaluation and intervention to prevent further complications. Monitoring for slurred speech helps in early detection and prompt management of a potential stroke.
Other choices such as A: Irregular pulse, B: Persistent fatigue, and C: Dependent edema are common in patients with heart failure and atrial fibrillation but are not immediate concerns requiring urgent intervention like slurred speech indicating a potential stroke.