Nokea
In assessing the healing of a client's wound during a home visit, which of the following is the best indicator of good healing?
- A. White patches.
- B. Green drainage.
- C. Reddened tissue.
- D. Eschar development.
Correct Answer: C
Rationale: Reddened tissue indicates healthy granulation tissue.
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A 44-year-old female client had an emergency cholecystectomy three days ago for a ruptured gallbladder. The client has severe abdominal pain, abdominal rigidity, distension, increased temperature, tachycardia and an elevated white blood count (WBC). The client has probably developed:
- A. gastritis.
- B. evisceration.
- C. peritonitis.
- D. a pulmonary embolism.
Correct Answer: C
Rationale: Assessment findings of gastritis would reveal anorexia, nausea and vomiting, epigastric fullness and tenderness, and discomfort. Evisceration is the extrusion of abdominal viscera as a result of trauma or sutures failing in a surgical incision. Peritonitis, inflammation of the peritoneum, can occur when an abdominal organ, such as the gallbladder, perforates and leaks blood and fluid into the abdominal cavity, which causes infection and irritation. Assessment findings of a pulmonary embolism would reveal severe substernal chest pain, tachycardia, tachypnea, shortness of breath, anxiety or panic, and wheezing and coughing, often accompanied by blood-tinged sputum.
For the nursing diagnoses and written patient outcomes listed below, use the Nursing Interventions Classification (NIC) to identify a specific nursing intervention to help the patient reach the outcome.
- A. Risk for impaired skin integrity related to immobility
- B. Constipation related to inadequate fluid and fiber intake
- C. None
- D. All
Correct Answer: A
Rationale: For preventing pressure ulcers, interventions like turning and positioning are critical. For constipation, increasing fluid and fiber intake is key.
What is the definition of substance abuse?
- A. A compulsive need to experience pleasure
- B. Behavior associated with maintaining an addiction
- C. Absence of a substance will cause withdrawal symptoms
- D. Overuse and dependence on a substance that negatively affects functioning.
Correct Answer: D
Rationale: Substance abuse involves overuse and dependence on a substance leading to negative impacts on one's life, encompassing both physical and social consequences.
What is the priority intervention for a patient admitted to your unit diagnosed with advanced amyotrophic lateral sclerosis (ALS)?
- A. Develop a method of communication.
- B. Provide six small meals high in protein and assist with feeding.
- C. Do not involve the patient in decisions about his healthcare because he is not in the mental state to respond.
- D. Provide six normal meals high in protein and assist with feeding.
Correct Answer: A
Rationale: Communication becomes critical as ALS progresses and affects motor functions.
Medications are given to older adults for many different conditions. A good rule to follow for medication use in older adults is to:
- A. Use once daily dosing
- B. Take all medications at the same time
- C. Request brand name medications
- D. Use the lowest possible effective dose
Correct Answer: D
Rationale: Older adults are more sensitive to medications due to decreased kidney and liver function. Using the lowest effective dose minimizes side effects and drug interactions.