Nokea
After tracheostomy procedure, the nurse documents important observation made during the procedure such us _________.
- A. Response of the patient's after procedure
- B. Vital signs of the patient's during the procedure
- C. Amount, color and consistency of sputum and appearance of the incision
- D. Behavior of the patient during the procedure
Correct Answer: C
Rationale: It is essential for the nurse to document important observations made during a tracheostomy procedure, and this includes the amount, color, and consistency of sputum as well as the appearance of the incision. Monitoring these factors helps assess the patient's respiratory status, risk of infection, and wound healing progress. Ensuring detailed documentation in this area allows for timely intervention if there are any concerning changes observed post-procedure. Observations such as the response of the patient, vital signs during the procedure, and patient behavior are also important but may be documented separately from the specific details related to sputum, incision appearance, and wound care.
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A patient presents with acute onset of severe headache, visual disturbances, and altered mental status. Imaging reveals a tumor compressing the optic chiasm. Which of the following neurological conditions is most likely responsible for these symptoms?
- A. Meningioma
- B. Glioblastoma multiforme
- C. Pituitary adenoma
- D. Medulloblastoma
Correct Answer: C
Rationale: Pituitary adenoma is the most likely neurological condition responsible for the described symptoms of acute onset severe headache, visual disturbances, and altered mental status when a tumor is found compressing the optic chiasm. Pituitary adenomas are benign tumors arising from the pituitary gland located at the base of the brain. As the tumor grows, it can compress nearby structures such as the optic chiasm, leading to visual disturbances (due to pressure on the optic nerves), severe headache (due to increased intracranial pressure), and altered mental status (due to effects on nearby brain structures).
A patient presents with a painless, gradually enlarging mass in the left neck, anterior to the sternocleidomastoid muscle. Fine-needle aspiration cytology reveals thyroid follicular cells. Which of the following conditions is most likely responsible for this presentation?
- A. Thyroglossal duct cyst
- B. Lymphadenopathy
- C. Thyroid adenoma
- D. Thyroid carcinoma
Correct Answer: C
Rationale: The presentation described is most consistent with a thyroid adenoma. Thyroid adenomas are benign neoplasms of the thyroid gland and can present as painless, gradually enlarging masses in the neck. Fine-needle aspiration cytology revealing thyroid follicular cells further supports the diagnosis of a thyroid adenoma. Thyroglossal duct cysts typically present as midline neck masses that move with swallowing, while lymphadenopathy presents as enlarged lymph nodes and may be associated with infection or malignancy. Thyroid carcinoma may also present as a neck mass but is more likely to be associated with other features such as vocal cord paralysis, hoarseness, or enlarged cervical lymph nodes.
A patient presents with a pruritic, eczematous rash with erythematous papules, vesicles, and excoriations on the flexural surfaces of the elbows and knees. The patient reports a personal history of asthma and hay fever. Which of the following conditions is most likely responsible for this presentation?
- A. Atopic dermatitis
- B. Contact dermatitis
- C. Seborrheic dermatitis
- D. Nummular eczema
Correct Answer: A
Rationale: Atopic dermatitis is a chronic, pruritic inflammatory skin condition that typically presents in individuals with a personal or family history of asthma and allergic rhinitis (hay fever). The characteristic presentation includes erythematous papules, vesicles, and excoriations on the flexural surfaces of the elbows and knees. This type of dermatitis is commonly seen in patients with atopy, which refers to a genetic predisposition to develop allergic diseases like asthma, hay fever, and eczema. Therefore, given the patient's personal history of asthma and hay fever along with the described rash distribution and appearance, atopic dermatitis is the most likely diagnosis.
Which of the following is the central theme of Sr. Calista Roys theory
- A. Self care deficit
- B. Nursing as caring
- C. Adaptation
- D. Transcultural
Correct Answer: C
Rationale: The central theme of Sr. Callista Roy's theory is adaptation. Roy's Adaptation Model focuses on the individual's ability to adapt to internal and external stimuli in order to maintain health and well-being. The theory emphasizes the interconnectedness of the individual and their environment, highlighting the dynamic process of adaptation in response to stimuli. By focusing on adaptation, Roy's theory guides nursing practice in promoting holistic care that supports individuals in adapting to changes and achieving optimal health outcomes.
While Mrs. Mely is on TPN she suddenly complained of slight chest pain, dyspnea and appears cyanotic. You suspect that she is experiencing what possible IMMEDIATE complication?
- A. Sepsis due to IV 1ine
- B. Hyperglycemia.
- C. Air embolism
- D. Allergic reaction to TPN
Correct Answer: C
Rationale: The symptoms described in the scenario - chest pain, dyspnea, and cyanosis - are indicative of a potential air embolism. Air embolism occurs when air enters the bloodstream, leading to blockages in blood vessels and impeding oxygen delivery to tissues. In patients receiving Total Parenteral Nutrition (TPN) through intravenous lines, the risk of air embolism exists during line manipulations, disconnections, or improper priming of the tubing. The sudden onset of symptoms like chest pain and cyanosis in a patient on TPN should raise suspicion for an air embolism, as it requires immediate intervention to prevent further complications such as cardiac arrest or stroke.