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A patient who received spinal anesthesia four hours ago during surgery is transferred to the surgical unit and, after 90 minutes, now reports severe incisional pain. The patient's blood pressure is 170/90 mmHg, pulse is 108 beats/min, temperature is 99oF (37.2oC), and respirations are 30 breaths/min. The patient's skin is pale, and the surgical dressing is dry and intact. The most appropriate nursing intervention is to
- A. medicate the patient for pain.
- B. place the patient in a high Fowler position and administer oxygen.
- C. place the patient in a reverse Trendelenburg position and open the IV line.
- D. report the findings to the provider.
Correct Answer: D
Rationale: The nurse should report these findings to the provider because the patient may be experiencing complications such as hypertension or hypovolemia.
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During an assessment, an older adult client's son reports that the client has been sick with a respiratory illness for the past 6 days. Which of the following assessment findings is a manifestation of pneumonia in the older adult client?
- A. Bradycardia
- B. Night sweats
- C. Confusion
- D. Narrowed pulse pressure
Correct Answer: C
Rationale: Step 1: Pneumonia in older adults often presents with atypical symptoms.
Step 2: Confusion is a common manifestation due to decreased oxygen levels.
Step 3: Respiratory illness can lead to hypoxia, causing confusion.
Step 4: Bradycardia, night sweats, and narrowed pulse pressure are not typical manifestations of pneumonia in older adults.
An 80-year-old patient is placed in isolation when infected with methicillin-resistant Staphylococcus aureus. The patient was alert and oriented on admission, but is now having visual hallucinations and can follow only simple directions. The medical-surgical nurse recognizes that the changes in the patient's mental status are related to
- A. a fluid and electrolyte imbalance.
- B. a stimulating environment.
- C. sensory deprivation.
- D. sundowning.
Correct Answer: C
Rationale: Isolation can lead to sensory deprivation, affecting cognitive function.
A college health nurse interprets the peak expiratory flow rate for a student who has asthma and finds that the student is in the yellow zone of his asthma action plan. The nurse should not base her actions on which of the following information?
- A. The student should use his quick-relief inhaler.
- B. The student's asthma is not well controlled.
- C. The student's peak flow is 50% to 80% of his best peak flow.
- D. The student needs to go to the hospital
Correct Answer: D
Rationale: The correct answer is D because the student being in the yellow zone indicates moderate symptoms, not severe enough to necessitate hospitalization. A: Using a quick-relief inhaler is appropriate for yellow zone symptoms. B: Yellow zone indicates asthma is not well controlled, supporting the need for action. C: Peak flow of 50% to 80% signals a reduction in lung function, requiring intervention but not immediate hospitalization. Thus, D is the incorrect choice because hospitalization is not warranted for yellow zone symptoms.
Allison Lynn, 20, is a student in a health sciences class and asks you to further explain the reason for lack of insulin in Type I Diabetes. You state that the most accepted theory is that:
- A. the insulin produced is not effective at the tissue level.
- B. not enough insulin is made to manage the metabolic needs.
- C. inflammation of the pancreas causes irregular release of insulin.
- D. the body's immune system destroyed the cells that make insulin.
Correct Answer: D
Rationale: Type I diabetes is the definition of that disease process that occurs when no insulin is produced, so there is no insulin to get to the cell level. Some Type II diabetes occurs because of insulin resistance. No insulin is being produced. This is one pathophysiological cause of Type II diabetes. Pancreatitis does cause irregular release of insulin, but not all people with pancreatitis develop Type I diabetes An autoimmune process is the most accepted theory of the root cause of Type I diabetes. The body produces an antibody which attacks and destroys the beta cells, leading to a lack of insulin.
During assessment, a healthcare provider is evaluating a client with chronic bronchitis. Which of the following percussion sounds should the healthcare provider expect?
- A. Dullness
- B. Resonance
- C. Tympany
- D. Flatness
Correct Answer: B
Rationale: The correct answer is B: Resonance. When assessing a client with chronic bronchitis, the healthcare provider should expect to hear resonant percussion sounds. This is because chronic bronchitis is characterized by inflammation and excess mucus production in the bronchial tubes, leading to airway obstruction. Resonance indicates normal lung tissue and air-filled spaces. Dullness (A) may suggest consolidation or fluid in the lungs, which is not typically associated with chronic bronchitis. Tympany (C) is a drum-like sound that can be heard over air-filled structures like the stomach, not typically expected in a lung assessment. Flatness (D) is heard over solid structures like the liver and would not be expected in a lung assessment for chronic bronchitis.