Nokea
Which of the following patients is at greatest risk for developing pressure ulcers?
- A. An alert chronic arthritic patient treated with steroids and aspirin
- B. An 88-year-old incontinent patient with gastric cancer who is confined to bed at home
- C. An apathetic 63-year-old COPD patient receiving nasal oxygen via cannula
- D. A confused 78-year-old patient with congestive heart failure (CHF) who requires assistance to get out of bed
Correct Answer: B
Rationale: The correct answer is B. An elderly patient who is incontinent, bedridden, and suffering from a serious illness like gastric cancer is at the highest risk for developing pressure ulcers. Being bedridden and incontinent increases the pressure on certain areas of the body, leading to tissue damage and the development of pressure ulcers. Additionally, the patient's age and underlying health condition further contribute to their risk. It is crucial to identify and address such risk factors promptly to prevent the occurrence of pressure ulcers in vulnerable patients.
You may also like to solve these questions
The four main concepts common to nursing that appear in each of the current conceptual models are:
- A. Person, nursing, environment, medicine
- B. Person, health, nursing, support systems
- C. Person, health, psychology, nursing
- D. Person, environment, health, nursing
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
What is the correct sequence for assessing the abdomen?
- A. Tympanic percussion, measurement of abdominal girth, and inspection
- B. Assessment for distention, tenderness, and discoloration around the umbilicus
- C. Percussion, palpation, and auscultation
- D. Auscultation, percussion, and palpation
Correct Answer: D
Rationale: The correct sequence for assessing the abdomen is auscultation, percussion, and palpation. Auscultation allows the healthcare provider to listen for bowel sounds, followed by percussion to assess for areas of tenderness or abnormal distention, and finally palpation to feel for masses or organ enlargement. This sequence ensures a systematic and thorough assessment of the abdomen.
For a rectal examination, the patient can be directed to assume which of the following positions?
- A. Genupectoral
- B. Sims
- C. Horizontal recumbent
- D. All of the above
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Why is a precise amount of oxygen necessary for a patient with COPD to prevent which complication?
- A. Cardiac arrest related to increased partial pressure of carbon dioxide in arterial blood (PaCO2)
- B. Circulatory overload due to hypervolemia
- C. Respiratory excitement
- D. Inhibition of the respiratory hypoxic stimulus
Correct Answer: D
Rationale: In patients with COPD, the respiratory drive is often stimulated by low oxygen levels. Administering too much oxygen can inhibit this hypoxic drive, leading to respiratory depression and potential respiratory failure. Therefore, it is crucial to carefully regulate the oxygen therapy to prevent the inhibition of the respiratory hypoxic stimulus in COPD patients.
The nurse observes that Mr. Adams begins to have increased difficulty breathing. She elevates the head of the bed to the high Fowler position, which decreases his respiratory distress. The nurse documents this breathing as:
- A. Tachypnea
- B. Eupnea
- C. Orthopnea
- D. Hyperventilation
Correct Answer: C
Rationale: Orthopnea is a condition where a person experiences difficulty breathing when lying flat but finds relief when sitting up or standing. Elevating the head of the bed to the high Fowler position helps alleviate this symptom. Tachypnea refers to rapid breathing, eupnea is normal breathing, and hyperventilation is breathing excessively fast or deep.