Nokea
Based on Virchow's Triad, select which patients below are at RISK for the development of a deep vein thrombosis? Select all that apply:
- A. A 55-year-old male with hyperlipidemia and diabetes.
- B. A 70-year-old female with severe sepsis.
- C. A 25-year-old male who uses intravenous drugs.
- D. A 65-year-old female who is post-op day 1 after joint replacement surgery.
Correct Answer: B,C,D
Rationale: Virchow's Triad details the THREE factors for blood clot formation within the vessel. Remember 'SHE': Stasis of Venous Blood, Hypercoagulability (means excessive coagulability), Endothelial damage. Patients who experience sepsis are at risk for hypercoagulability of the blood. Patients who use IV drugs damage the endothelial lining of the veins and this can lead to blood clot formation. Patients who've had joint replacement surgery are at risk for blood clots due to stasis of venous circulation etc.
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The client is admitted to a medical unit with a diagnosis of pneumonia. Which signs and symptoms should the nurse assess in the client?
- A. Pleuritic chest discomfort and anxiety.
- B. Asymmetrical chest expansion and pallor.
- C. Leukopenia and CRT <three (3) seconds.
- D. Substernal chest pain and diaphoresis.
Correct Answer: A
Rationale: Pneumonia causes pleuritic chest pain and anxiety (A) from inflammation/hypoxia. Asymmetry (B) suggests pneumothorax, leukopenia (C) is atypical, and substernal pain (D) suggests MI.
The client is diagnosed with mild intermittent asthma. Which medication should the nurse discuss with the client?
- A. Daily inhaled corticosteroids.
- B. Use of a 'rescue inhaler.'
- C. Use of systemic steroids.
- D. Leukotriene agonists.
Correct Answer: B
Rationale: Mild intermittent asthma requires a rescue inhaler (B) (e.g., albuterol) for PRN use. Daily corticosteroids (A), systemic steroids (C), and leukotrienes (D) are for persistent asthma.
Which of the following best indicates that the client's grief is beginning to resolve?
- A. The client wants only the spouse to visit.
- B. The client says the physician made an incorrect diagnosis.
- C. The client looks at the tracheostomy tube in a mirror.
- D. The client asks the nurse for help with bathing.
Correct Answer: C
Rationale: Looking at the tracheostomy tube in a mirror suggests acceptance of the body image change, indicating progress in resolving grief.
The wife of a client with active tuberculosis has a positive skin test for tuberculosis. She is to be started on prophylactic drug therapy. What drug is the drug of choice for prophylaxis of tuberculosis?
- A. Streptomycin
- B. Para-aminosalicylic (PAS) acid
- C. Isoniazid (INH)
- D. Ethambutol (Myambutol)
Correct Answer: C
Rationale: Isoniazid is the drug of choice for tuberculosis prophylaxis due to its effectiveness in preventing active disease.
The client has had a total laryngectomy. Which referral is specific for this surgery?
- A. CanSurmount.
- B. Dialogue.
- C. Lost Chord Club.
- D. SmokEnders.
Correct Answer: C
Rationale: Lost Chord Club (C) supports laryngectomy patients with communication and adjustment. CanSurmount (A), Dialogue (B), and SmokEnders (D) are for cancer, CLL, and smoking cessation.