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A patient with peripheral vascular disease is receiving discharge instructions. Which of the following information should be included?
- A. Walk barefoot whenever possible.
- B. Use a heating pad to keep feet warm.
- C. Avoid crossing the legs.
- D. Use antibacterial ointment to treat skin lesions prone to infection.
Correct Answer: C
Rationale: Patients with peripheral vascular disease should be advised to avoid crossing their legs as this can impede blood flow. Peripheral vascular disease, also known as arteriosclerosis obliterans, is primarily caused by atherosclerosis. Atherosclerosis results in the gradual progression of arterial occlusion due to the formation of atheromas. Crossed legs can further restrict blood flow, exacerbating the condition. Walking barefoot should be discouraged to prevent potential injuries to the feet. Using a heating pad can lead to burns and should be avoided to prevent thermal injuries. While using antibacterial ointment for skin lesions may be beneficial, it is not the priority instruction for patients with peripheral vascular disease.
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You are creating a teaching plan for a patient with newly diagnosed migraine headaches. Which key item should NOT be included in the teaching plan?
- A. Avoid foods that contain tyramine, such as alcohol and aged cheese.
- B. Avoid drugs such as Tagamet, nitroglycerin, and Nifedipine.
- C. Continue taking estrogen as prescribed by your physician.
- D. A potential side effect of medications is rebound headache.
Correct Answer: C
Rationale: The correct answer is C: Continue taking estrogen as prescribed by your physician. Medications such as estrogen supplements may actually trigger a migraine headache attack. Fluctuations in estrogen, such as before or during menstrual periods, pregnancy, and menopause, seem to trigger headaches in many women. Choices A and B are important to include in the teaching plan for a patient with migraines as avoiding foods containing tyramine and certain drugs can help prevent migraine triggers. Choice D is also relevant as it is essential for the patient to be aware of potential side effects of medications, including rebound headaches.
An infant is brought to the clinic by his mother, who has noticed that he holds his head in an unusual position and always faces to one side. Which of the following is the most likely explanation?
- A. Torticollis, with shortening of the sternocleidomastoid muscle
- B. Craniosynostosis, with premature closure of the cranial sutures
- C. Plagiocephaly, with flattening of one side of the head
- D. Hydrocephalus, with increased head size
Correct Answer: A
Rationale: The correct answer is torticollis, characterized by the shortening of the sternocleidomastoid muscle, limiting the range of motion of the neck and causing the chin to point to the opposing side. Craniosynostosis is the premature closure of cranial sutures, leading to an abnormal head shape but not necessarily affecting head position. Plagiocephaly is flattening of one side of the head due to external forces or positioning, not muscle shortening. Hydrocephalus presents with an increased head size due to the accumulation of cerebrospinal fluid, not with a fixed head position.
A patient with peripheral vascular disease is receiving discharge instructions. Which of the following information should be included?
- A. Walk barefoot whenever possible.
- B. Use a heating pad to keep feet warm.
- C. Avoid crossing the legs.
- D. Use antibacterial ointment to treat skin lesions prone to infection.
Correct Answer: C
Rationale: Patients with peripheral vascular disease should be advised to avoid crossing their legs as this can impede blood flow. Peripheral vascular disease, also known as arteriosclerosis obliterans, is primarily caused by atherosclerosis. Atherosclerosis results in the gradual progression of arterial occlusion due to the formation of atheromas. Crossed legs can further restrict blood flow, exacerbating the condition. Walking barefoot should be discouraged to prevent potential injuries to the feet. Using a heating pad can lead to burns and should be avoided to prevent thermal injuries. While using antibacterial ointment for skin lesions may be beneficial, it is not the priority instruction for patients with peripheral vascular disease.
The nurse is caring for a woman 2 hours after a vaginal delivery. Documentation indicates that the membranes were ruptured for 36 hours prior to delivery. What are the priority nursing diagnoses at this time?
- A. Altered tissue perfusion
- B. Risk for fluid volume deficit
- C. High risk for hemorrhage
- D. Risk for infection
Correct Answer: D
Rationale: The correct answer is 'Risk for infection.' When membranes are ruptured for over 24 hours before delivery, there is a significantly increased risk of infection for both the mother and the newborn. Factors such as increased local cytokines, an imbalance in enzyme activity, and increased intrauterine pressure contribute to this risk. 'Altered tissue perfusion' is not the priority in this scenario as there is no indication of compromised blood flow. 'Risk for fluid volume deficit' is not the priority as there are no signs of excessive fluid loss. 'High risk for hemorrhage' is not the priority as the question does not suggest active bleeding as an immediate concern.
Which action represents the evaluation stage of the plan of care?
- A. The nurse assigns a nursing diagnosis of Impaired Skin Integrity related to diminished skin circulation
- B. The nurse assesses the client's vital signs and asks about symptoms
- C. The nurse determines that the client is not meeting his set outcomes and makes revisions
- D. The nurse discusses the client's health history
Correct Answer: C
Rationale: The correct answer is C. The evaluation stage of the nursing process involves reviewing the assessments, diagnoses, and interventions given to the client and then determining if the client is meeting expected outcomes. In this scenario, the nurse is assessing whether the client is meeting the outcomes set for their care plan and making revisions as needed. Choice A is incorrect as assigning a nursing diagnosis is part of the nursing diagnosis phase, not the evaluation phase. Choice B represents the assessment phase of the nursing process, not the evaluation phase. Choice D involves discussing the client's health history, which is more aligned with the assessment phase rather than the evaluation phase.