Nokea
A client returns from surgery after having a colon resection. The nurse is performing an assessment and notes the wound edges have separated. This condition is called:
- A. Evisceration
- B. Hematoma
- C. Dehiscence
- D. Granulation
Correct Answer: C
Rationale: Wound dehiscence occurs when the edges of a wound pull apart. The condition may occur following a surgical procedure if the sutures were deficient. Wound dehiscence may also occur following a wound infection or in cases where a client significantly stretches or overuses the associated tissues. Evisceration refers to the protrusion of internal organs through an open wound. Hematoma is a localized collection of blood outside the blood vessels. Granulation is the formation of new connective tissue and tiny blood vessels on the surface of a wound during the healing process.
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What factors should the nurse consider for teaching a child about his or her disease and related health care measures?
- A. A child rarely forms misconceptions.
- B. The older the child, the shorter the attention span.
- C. A child's imagination may create greater fear than the truth.
- D. A child may regress developmentally in a situation of illness.
- E. It is not necessary to assess the child's knowledge before teaching.
- F. A child may better manage uncomfortable information through role-playing.
Correct Answer: C,D,F
Rationale: For children, the teaching-learning process may be fundamentally different from that used for adults, and the nurse needs to adjust the complexity and volume of information based on the child's age and cognitive level. The factors that need to be addressed when teaching children include the following: Trust is essential to a therapeutic relationship; in general, the younger the child, the shorter the attention span; assessing the child's knowledge is important because children are exposed to various levels of information about health care; children form misconceptions easily, and a child's imagination may create greater fear than the truth; a child may regress developmentally in a situation of illness; and a child may better manage uncomfortable information through role-playing.
A nurse is caring for a client who is post-op day #1 after a total hip replacement. Although the client was alert with a normal affect in the morning, by lunchtime, the nurse notes the client is confused, has slurred speech, and is having trouble with her balance. Her blood glucose level is 48 mg/dl. What is the next action of the nurse?
- A. Contact the physician immediately
- B. Administer a bolus of 50 cc of D20W through the IV
- C. Administer 10 units of regular insulin
- D. Give the client 6 oz. of orange juice
Correct Answer: D
Rationale: A client with a blood glucose level of 48 mg/dl is experiencing significant hypoglycemia, as manifested by confusion, balance difficulties, and slurred speech. The nurse should work to correct this situation as rapidly as possible. The first measure that can be performed quickly and will have fast results is to give the client something to eat or drink that contains glucose, such as 6 oz. of orange juice. Administering a bolus of D20W through the IV (Choice B) would be too aggressive and could lead to complications in this scenario. Administering regular insulin (Choice C) would further lower the blood glucose level, worsening the client's symptoms. Contacting the physician (Choice A) is important, but immediate intervention to raise the blood glucose level is crucial to address the client's hypoglycemia.
A client has started sweating profusely due to intense heat. His overall luid volume is low and he has developed electrolyte imbalance. This client is most likely suffering from:
- A. Malignant hyperthermia
- B. Heat exhaustion
- C. Heat stroke
- D. Heat cramps
Correct Answer: B
Rationale: Heat exhaustion occurs when a person has enough diaphoresis that he becomes dehydrated. Intense sweating can cause both luid and electrolyte imbalances. Untreated heat exhaustion canlead to heat stroke, which results in organ damage, loss of consciousness, or death.
A nurse is caring for an 83-year-old man who has had swallowing difficulties. All of the following interventions are appropriate for this client EXCEPT:
- A. Keep the client in an upright position at all times
- B. Auscultate lung sounds every shift and after feedings
- C. Maintain suction equipment at the client's bedside
- D. Instruct the client about how to perform swallowing exercises
Correct Answer: A
Rationale: When caring for a client with swallowing difficulties, it is crucial to prevent aspiration of food into the lungs. Appropriate interventions include auscultating lung sounds every shift and after feedings to assess for any changes in breathing patterns, maintaining suction equipment at the client's bedside in case of difficulties, and providing instruction on swallowing exercises. Keeping the client in an upright position at all times is not necessary and may not always be feasible or comfortable for the client. This rigid requirement is not part of the standard care protocol for managing swallowing difficulties.
Clonazepam has been prescribed for the client, and the nurse teaches the client about the medication. Which statement by the client indicates that further teaching is necessary?
- A. If I experience slurred speech, it will disappear in about 8 weeks.
- B. My drowsiness will decrease over time with continued treatment.
- C. I should take my medicine with food to decrease stomach problems.
- D. I can take my medicine at bedtime if it tends to make me feel drowsy.
Correct Answer: A
Rationale: Clonazepam is a benzodiazepine. Clients who experience signs/symptoms of toxicity with the administration of clonazepam exhibit slurred speech, sedation, confusion, respiratory depression, hypotension, and eventually coma. Some drowsiness may occur, but it will decrease with continued use. The medication may be taken with food to decrease gastrointestinal irritation. The medication may be taken at bedtime if drowsiness does occur. Slurred speech indicates toxicity and should be reported immediately, not expected to disappear in 8 weeks.