Nokea
An 80-year-old patient is admitted with dyspnea, dependent edema, rales, and distended neck veins. As the nurse monitors the patient, he becomes increasingly short of breath and begins to have cardiac dysrhythmias. The most critical intervention for this patient is to:
- A. Ensure his airway is open and unobstructed.
- B. Apply oxygen to maintain his oxygen saturation above 94%.
- C. Administer Dobutamine to increase cardiac output.
- D. Start an IV for monitoring fluid intake.
Correct Answer: A
Rationale: In a patient presenting with dyspnea, dependent edema, rales, distended neck veins, and developing cardiac dysrhythmias, the priority intervention is to ensure the airway is open and unobstructed. Maintaining an open airway is crucial for adequate ventilation and oxygenation, especially in a patient showing signs of impending respiratory distress and cardiac compromise. While applying oxygen to maintain oxygen saturation is important, ensuring airway patency takes precedence as it directly impacts the patient's ability to breathe. Administering Dobutamine may be necessary to improve cardiac output; however, addressing the airway first is essential to prevent further respiratory distress and worsening dysrhythmias. Starting an IV for monitoring fluid intake is not the most critical intervention in this scenario compared to ensuring airway patency and oxygenation.
You may also like to solve these questions
The physician has decided to perform a thoracentesis based on Mr. R's assessment. Which of the following actions from the nurse is most appropriate?
- A. Instruct the client not to talk during the procedure
- B. Assist the client to sit upright or slightly lean forward
- C. Insert a 20-gauge needle just above the 4th intercostal space
- D. Connect the needle to suction to remove fluid that has collected in the pleural space
Correct Answer: A
Rationale: The correct answer is to instruct the client not to talk during the procedure. This is important to prevent air from being drawn into the pleural space during the thoracentesis. Choice B is incorrect because the client should be sitting upright or slightly leaning forward during the procedure to facilitate access to the pleural space. Choice C is incorrect as the nurse should not perform the thoracentesis procedure, which involves inserting a needle into the pleural space - this is the physician's responsibility. Choice D is incorrect as connecting the needle to suction to remove fluid is not the appropriate procedure for a thoracentesis. Thoracentesis is typically done to remove fluid or air for diagnostic or therapeutic purposes, not to connect to suction to remove fluid that has collected in the pleural space.
A patient is being visited at home by a healthcare professional. The patient has been taking Naproxen for back pain. Which statement made by the patient most indicates that the healthcare professional needs to contact the physician?
- A. I get an upset stomach if I don't take Naproxen with my meals.
- B. My back pain right now is about a 3/10.
- C. I get occasional headaches since taking Naproxen
- D. I have ringing in my ears.
Correct Answer: D
Rationale: The correct answer is 'I have ringing in my ears.' Ringing in the ears is a severe adverse effect of Naproxen, indicating potential toxicity. This symptom warrants immediate medical attention. Choices A, B, and C are less concerning and do not directly indicate a severe adverse effect or toxicity related to Naproxen. Upset stomach, mild back pain, and occasional headaches are common side effects that may not require immediate physician contact.
Which of the following statements made by a client during an individual therapy session would the nurse most identify as reflecting schizoaffective disorder?
- A. I just want to stab myself with this pen.''
- B. What's the point in life anyways?''
- C. My thoughts are racing because of the conspiracies against me.''
- D. I hear voices every day and sometimes see old friends that don't exist.''
Correct Answer: C
Rationale: The correct answer is, ''My thoughts are racing because of the conspiracies against me.'' Schizoaffective disorder combines the symptoms of bipolar disorder (mania and depression) with those of schizophrenia (delusions and disturbed thought processes). Racing thoughts are a characteristic symptom of a manic episode, while beliefs in conspiracies indicate paranoia, which are common in schizoaffective disorder. Choices A, B, and D do not specifically align with the symptoms of schizoaffective disorder. Choice A suggests self-harm, which may be seen in various mental health conditions; choice B reflects existential questioning or depression; and choice D describes hallucinations, which are more characteristic of schizophrenia rather than schizoaffective disorder.
Which of the following can cause coup-contrecoup injuries?
- A. Rotational forces
- B. Deformation forces
- C. Deceleration forces
- D. Acceleration forces
Correct Answer: C
Rationale: Deceleration forces occur when the head is moving and abruptly comes to a stop, such as in a car crash. This sudden deceleration can cause the brain to hit against the skull, resulting in coup-contrecoup injuries. In a coup-contrecoup injury, the brain is damaged on opposite sides due to the initial impact and the rebound effect inside the skull. Rotational forces usually result in diffuse axonal injuries rather than coup-contrecoup injuries. Deformation forces can cause focal brain injuries but not coup-contrecoup injuries. Acceleration forces typically lead to diffuse brain injuries, not coup-contrecoup injuries. Therefore, the correct answer is deceleration forces.
A 25-year-old male client has been newly diagnosed with hypothyroidism and will take levothyroxine (Synthroid) 50 mcg/day by mouth. As part of the teaching plan, the nurse emphasizes that this medication:
- A. Should be taken in the morning
- B. May increase the client's energy level
- C. Does not need to be stored in a dark container
- D. May increase the client's heart rate
Correct Answer: A
Rationale: The correct answer is that levothyroxine (Synthroid) should be taken in the morning. Taking it in the morning can help prevent interference with the client's sleeping pattern, as one of the side effects of levothyroxine is insomnia. Choice B is incorrect because levothyroxine is actually used to treat hypothyroidism and can help increase energy levels. Choice C is incorrect as there is no specific requirement for levothyroxine to be stored in a dark container. Choice D is incorrect because levothyroxine is more likely to increase heart rate rather than decrease it.