Nokea
An adult is diagnosed with disseminated intravascular coagulation. The nurse should identify that the client is at risk for which of the following nursing diagnosis?
- A. Risk for increased cardiac output related to fluid volume excess
- B. Disturbed sensory perception related to bleeding into tissues
- C. Alteration in tissue perfusion related to bleeding and diminished blood flow
- D. Risk for aspiration related to constriction of the respiratory musculature
Correct Answer: C
Rationale: The correct answer is C: Alteration in tissue perfusion related to bleeding and diminished blood flow. Disseminated intravascular coagulation (DIC) is a condition where blood clots form throughout the body, leading to both bleeding and clotting. This can result in decreased blood flow to tissues, causing tissue perfusion issues.
Explanation:
1. Option A: Risk for increased cardiac output related to fluid volume excess is incorrect because DIC can lead to bleeding, causing a decrease in blood volume and potentially decreasing cardiac output.
2. Option B: Disturbed sensory perception related to bleeding into tissues is incorrect as DIC primarily affects blood clotting and bleeding, not sensory perception.
3. Option D: Risk for aspiration related to constriction of the respiratory musculature is incorrect as DIC does not directly cause constriction of respiratory muscles, but rather impacts the clotting and bleeding processes in the body.
In summary, the correct answer is C because DIC can lead to altered tissue perfusion
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The most likely cause of her chief complaint this morning is
- A. A decrease in postoperative stress causing poiyuria
- B. The onset of diabetes mellitus, an unusual complication
- C. An expected result of the removal of the pituitary gland
- D. A frequent complication of the hypophysectomy
Correct Answer: D
Rationale: The correct answer is D because polyuria is a common complication following hypophysectomy (removal of the pituitary gland). This procedure can disrupt the regulation of antidiuretic hormone (ADH), leading to excessive urination. Choice A is incorrect as decreased stress would not cause polyuria. Choice B is unlikely as the onset of diabetes mellitus is not a typical immediate postoperative complication. Choice C is incorrect as removal of the pituitary gland would disrupt hormone regulation, possibly leading to polyuria, rather than being an expected result.
Clients with myastherda gravis, Guillain - Barre Syndrome or amyothrophic sclerosis experience:
- A. Progressive deterioration until death
- B. Deficiencies of essential neurotransmitter
- C. Increased risk of respiratory complications
- D. Involuntary twitching of small muscle group
Correct Answer: C
Rationale: The correct answer is C: Increased risk of respiratory complications. Clients with myasthenia gravis, Guillain-Barre Syndrome, or amyotrophic lateral sclerosis may experience respiratory muscle weakness, leading to difficulty breathing and an increased risk of respiratory complications such as pneumonia or respiratory failure. This is due to the involvement of the muscles responsible for breathing in these conditions. Progressive deterioration until death (A) is not always the case and varies depending on the condition and individual. Deficiencies of essential neurotransmitters (B) is not a common symptom in these conditions. Involuntary twitching of small muscle groups (D) is not a characteristic symptom of these neurological disorders.
A patient admitted with gastrointestinal tract bleeding has a hemoglobin level of 6 g/dL. She asks the nurse why she feels SOB. Which response is best?
- A. “Anemia prevents your lungs from absorbing oxygen effectively.”
- B. “You do not have enough hemoglobin to carry oxygen to your tissues.”
- C. “”You don’t have enough blood to feed your cells.”
- D. “You have lost a lot of blood, and that has damaged your lungs.”
Correct Answer: B
Rationale: The correct answer is B because hemoglobin carries oxygen to the tissues, and with a low hemoglobin level of 6 g/dL, there is insufficient oxygen-carrying capacity to meet the body's needs, leading to shortness of breath (SOB). Choice A is incorrect as anemia affects oxygen transport, not absorption. Choice C is incorrect as anemia affects oxygen delivery, not nutrient delivery. Choice D is incorrect as the primary reason for SOB in this scenario is the lack of oxygen-carrying capacity due to low hemoglobin levels, not lung damage from blood loss.
After reviewing the database, the nurse discovers that the patient’s vital signs have not been recorded by the nursing assistive personnel (NAP). Which clinical decision should the nurse make? Administer scheduled medications assuming that the NAP would have reported
- A. abnormal vital signs. Have the patient transported to the radiology department for a scheduled x-ray, and
- B. review vital signs upon return.
- C. Ask the NAP to record the patient’s vital signs before administering medications.
- D. Omit the vital signs because the patient is presently in no distress.
Correct Answer: C
Rationale: Rationale for Correct Answer (C):
1. Safety first: Patient safety is the top priority in healthcare. Vital signs provide crucial information about the patient's condition.
2. Accountability: The nurse is responsible for ensuring accurate vital sign documentation. Asking the NAP to record vital signs before medication administration ensures accountability.
3. Communication: Clear communication between healthcare team members is essential to provide quality care. Asking the NAP to record vital signs promotes effective communication.
Summary of Incorrect Choices:
A (abnormal vital signs): Administering medications without knowing the patient's vital signs, especially if abnormal, can be dangerous and potentially harmful.
B (review upon return): Delaying vital sign assessment until later can lead to missed opportunities for timely intervention if the patient's condition changes.
D (omit vital signs): Neglecting vital signs based on assumption risks overlooking potential issues that could impact patient care and outcomes.
Which of the following positions would be most appropriate for a patient with right-sided paralysis following a stroke?
- A. On the side with support to the back, with pillows to keep the body in alignment, hips slightly flexed, and hands tightly holding a rolled washcloth.
- B. On the side with support to the back, pillows to keep the body in alignment, hips slightly flexed, and a washcloth placed so that fingers are slightly curled.
- C. On the back with two large pillows under the head, pillow under" the knees, and a footboard.
- D. On the back with no pillows used, with trochanter rolls and a footboard.
Correct Answer: B
Rationale: The correct answer is B. Placing the patient on the right side with support to the back, pillows for body alignment, hips slightly flexed, and a washcloth placed so that fingers are slightly curled is most appropriate for a patient with right-sided paralysis following a stroke. This position helps prevent contractures by maintaining proper alignment and positioning of the limbs. Placing the washcloth to curl the fingers helps prevent hand contractures. Supporting the back and keeping the hips slightly flexed also helps prevent pressure ulcers and maintains proper body alignment.
Choice A is incorrect because tightly holding a rolled washcloth may cause discomfort and restrict blood flow.
Choice C is incorrect because placing the patient on the back with a pillow under the knees does not address the specific needs of a patient with right-sided paralysis.
Choice D is incorrect because lying on the back with trochanter rolls and a footboard does not address the specific needs of a patient with right-sided paralysis and may not prevent contractures effectively.