Nokea
Priority Decision: A patient in the PACU has emergence delirium manifested by agitation and thrashing. What should the nurse assess for first in the patient?
- A. Hypoxemia
- B. Neurologic injury
- C. Distended bladder
- D. Cardiac dysrhythmias
Correct Answer: A
Rationale: Hypoxemia is a common cause of agitation and delirium during emergence from anesthesia.
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Which concept characterizes culture as continuously evolving?
- A. Learned from birth through language and socialization.
- B. Learned by members of the same cultural group.
- C. Influenced by specific conditions related to environment,technology and availability of resources.
- D. Dynamic and ever-changing.
Correct Answer: D
Rationale: Culture evolves dynamically, adapting to environmental, technological, and resource-related changes over time.
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.
A client with emphysema is being cared for by a nurse. Which of the following findings should the nurse not expect to assess in this client?
- A. Dyspnea
- B. Bradycardia
- C. Barrel chest
- D. Clubbing of the fingers
Correct Answer: B
Rationale: Step 1: Emphysema causes impaired gas exchange, leading to dyspnea (A) due to difficulty breathing.
Step 2: Emphysema results in hyperinflation of the lungs, causing a barrel chest (C) due to increased chest diameter.
Step 3: Clubbing of the fingers (D) is a sign of chronic hypoxia, commonly seen in emphysema.
Step 4: Bradycardia (B) is not typically associated with emphysema; tachycardia is more common due to the body compensating for hypoxia.
During the rehabilitative phase following his cerebrovascular accident, Mr. K. is taught measures to relieve or prevent constipation. Which of these statements indicates that Mr. K. needs further health teaching?
- A. I eat whole-wheat bread with my meals.'
- B. I eat fruit three times a day.'
- C. I don't drink fluids after 4 P.M.'
- D. I don't like to take enemas.'
Correct Answer: C
Rationale: Restricting fluid intake after 4 P.M. can contribute to dehydration and constipation, making this statement indicative of the need for further education on proper hydration practices.
What information should be immediately reported to the physician?
- A. The ingested children's chewable vitamins contain iron
- B. The child has been treated several times for ingestion of toxic substances
- C. The child has been treated several times for accidental injuries
- D. The child was nauseated and vomited once at home
Correct Answer: A
Rationale: Iron ingestion can cause severe toxicity and requires immediate medical attention.