Nokea
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.
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A nurse is assessing a client who has rheumatoid arthritis. Which of the following findings should the nurse expect?
- A. Unilateral joint involvement.
- B. Ulnar deviation.
- C. Decreased sedimentation rate.
- D. Fractures of the spine.
Correct Answer: B
Rationale: The correct answer is B: Ulnar deviation. In rheumatoid arthritis, ulnar deviation of the fingers is a common finding due to inflammation and destruction of the joints. This deformity leads to the fingers deviating towards the ulnar side of the hand. This is a characteristic feature seen in rheumatoid arthritis and is caused by the inflammation affecting the joints. Choices A, C, and D are incorrect. A: Unilateral joint involvement is not typical of rheumatoid arthritis, as it usually affects multiple joints symmetrically. C: Decreased sedimentation rate is not expected in rheumatoid arthritis, as it is typically associated with an elevated sedimentation rate due to inflammation. D: Fractures of the spine are not a common finding in rheumatoid arthritis, as it primarily affects the joints.
A client arrived via ambulance to the emergency department with a chief complaint of gastrointestinal bleeding for 2 hours. What will the triage nurse do first?
- A. Insert a nasogastric (NG) tube.
- B. Ask the client about the precipitating events.
- C. Obtain vital signs.
- D. Complete a head-to-toe assessment.
Correct Answer: C
Rationale: The correct answer is C: Obtain vital signs. The first step in triaging a patient with gastrointestinal bleeding is to assess their vital signs to determine the severity of the situation. Vital signs, such as blood pressure, heart rate, respiratory rate, and oxygen saturation, provide crucial information about the patient's condition and help prioritize the level of care needed. This immediate assessment allows the triage nurse to identify any signs of shock or instability, guiding further interventions and treatment. Inserting an NG tube (choice A) or completing a head-to-toe assessment (choice D) can wait until the patient's vital signs are stable and the immediate risk is addressed. Asking about precipitating events (choice B) may provide important information but is not as urgent as assessing vital signs in this critical situation.
A nurse in the outpatient clinic is assessing a client who has psoriasis. The nurse should expect which of the following findings?
- A. Silvery, white scales.
- B. Intense pain.
- C. Unilateral lesions.
- D. Serous drainage.
Correct Answer: A
Rationale: The correct answer is A: Silvery, white scales. Psoriasis is characterized by the presence of silvery, white scales on the skin due to rapid skin cell turnover. This finding is classic for psoriasis. Intense pain (B) is not a typical symptom of psoriasis; it is more commonly associated with conditions like shingles. Unilateral lesions (C) would not be expected in psoriasis, as it often affects both sides of the body symmetrically. Serous drainage (D) is not a typical feature of psoriasis, which primarily presents with dry, scaly patches.
A nurse in an emergency department is caring for a client who has deep partial- and full-thickness burns to his face, chest, abdomen, and upper arms. What is the nurse’s priority intervention for this client during the resuscitation phase of injury?
- A. Medicate for pain.
- B. Maintain the airway.
- C. Insert an indwelling urinary catheter.
- D. Initiate fluid resuscitation.
Correct Answer: B
Rationale: The correct answer is B: Maintain the airway. During the resuscitation phase of burn injuries, priority is given to ensuring airway patency to prevent respiratory distress and failure. Burns to the face, chest, and abdomen can lead to airway compromise due to swelling and damage. Maintaining the airway is crucial to ensure adequate oxygenation and ventilation. Pain management (choice A) is important but not the priority in this phase. Inserting a urinary catheter (choice C) is not a priority during the resuscitation phase. Initiating fluid resuscitation (choice D) is important but only after ensuring airway patency.
A nurse is caring for an older adult client who had a femoral head fracture 24 hr ago and is in skin traction. The client reports shortness of breath and dyspnea. The nurse should suspect that the client has developed which of the following complications?
- A. Airway obstruction.
- B. Pneumonia.
- C. Pneumothorax.
- D. Fat embolism.
Correct Answer: D
Rationale: The correct answer is D: Fat embolism. Fat embolism can occur in clients with long bone fractures, like a femoral head fracture. Fat emboli can travel to the lungs leading to respiratory distress, shortness of breath, and dyspnea. This is a potential complication that can occur within the first 24-48 hours post-injury. Fat embolism is characterized by respiratory symptoms and can lead to hypoxia and respiratory failure.
Other choices are incorrect because:
A: Airway obstruction typically presents with choking or difficulty swallowing, not specifically with shortness of breath and dyspnea.
B: Pneumonia would typically present with fever, productive cough, and chest pain, not sudden-onset shortness of breath.
C: Pneumothorax presents with sudden chest pain and shortness of breath due to air in the pleural space, not directly related to a femoral head fracture.
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