Nokea
In developing a discharge plan for a patient requiring home-care services, what is important to assess?
- A. Patient’s nursing diagnosis
- B. Availability of needed community services
- C. Patient’s functional abilities
- D. Patient’s family dynamics
Correct Answer: B
Rationale: Ensuring access to necessary community services is vital for successful home care.
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Because of the rapid elimination of volatile liquids used for general anesthesia, what should the nurse anticipate the patient will need early in the anesthesia recovery period?
- A. Warm blankets
- B. Analgesic medication
- C. Observation for respiratory depression
- D. Airway protection in anticipation of vomiting
Correct Answer: C
Rationale: Rapid elimination can lead to respiratory depression, necessitating close observation.
In a Hispanic patient who claims to have empacho, what assessment findings would the nurse expect?
- A. Abdominal pain and cramping
- B. Anxiety,insomnia anorexia and social isolation
- C. Nightmares weakness and a sense of suffocation
- D. Headaches,stomach problems and loss of consciousness
Correct Answer: A
Rationale: Empacho is a folk illness commonly reported among Hispanic populations, characterized by abdominal pain and cramping due to perceived blockage in the digestive system.
A client had a hemicolectomy performed two days ago. Today, the nurse assessed the incision and discovered a small part of the abdominal viscera protruding through the incision. This complication of wound healing is known as:
- A. excoriation.
- B. dehiscence.
- C. decortication.
- D. evisceration.
Correct Answer: D
Rationale: Excoriation is an abrasion of the epidermis, or of any organ coating of the body, caused by trauma, chemicals, burns, or other causes. Dehiscence is a partial to complete separation of the wound edges with no abdominal tissue protrusion. Decortication is removal of the surface layer of an organ or structure, such as removing the fibrinous peel from the visceral pleura in thoracic surgery. Evisceration occurs when the incision separates and the contents of the cavity spill out.
Which setting allows the dying client to have advanced care in an institution due to the necessity to control pain unable to be managed at home?
- A. Hospice care
- B. Acute care
- C. Palliative care
- D. Home care
Correct Answer: C
Rationale: Palliative care specializes in managing complex symptoms and pain, providing advanced institutional support.
Which assessment finding signals the most serious and life-threatening condition?
- A. A deviated trachea
- B. Gross deformity in a lower extremity
- C. Decreased breath sounds
- D. Hemoptysis
Correct Answer: A
Rationale: A deviated trachea indicates possible tension pneumothorax, a life-threatening condition.