Nokea
The nurse is conducting an assessment to her patient who has edema of the lower extremities due to congestive heart failure. If edema is graded on a scale of +1 (no visible edema in the leg) to 4+ (leg very swollen), what will the Nurse document in her chart if her assessment findings of the edema is SLIGHTLY swollen?
- A. 4
- B. 2
- C. 1
- D. 3
Correct Answer: B
Rationale: In the grading system used for edema, +1 indicates no visible edema in the leg, +2 indicates slight edema with indentations that quickly resolve, +3 indicates moderate edema with deeper indentations that may take longer to resolve, and +4 indicates severe edema with very swollen legs. In this case, since the edema is described as slightly swollen, the appropriate grade to document would be +2.
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Which of the following actions is recommended for controlling severe external bleeding from an extremity?
- A. Applying a tourniquet proximal to the injury site.
- B. Elevating the extremity above the level of the heart.
- C. Applying direct pressure with a sterile dressing.
- D. Removing any impaled objects.
Correct Answer: C
Rationale: When controlling severe external bleeding from an extremity, the recommended action is to apply direct pressure with a sterile dressing. Direct pressure helps to stop the bleeding by promoting clot formation and reducing blood flow from the wound. This method is effective in most cases and should be the first response to control bleeding. Elevating the extremity above the level of the heart can be helpful in some cases, but direct pressure is the initial recommended action. Applying a tourniquet proximal to the injury site should only be done as a last resort when other methods are not successful, as it can lead to complications such as tissue damage. Removing any impaled objects can actually worsen the bleeding and should be avoided unless necessary for immediate life-saving measures.
The nurse did an admission procedure. The best position to be assumed by Roy is _____.
- A. left lateral position with the affected side inferior.
- B. semi-fowler position at least 30 degrees.
- C. dorsal position with pillows under the chest.
- D. lying on his side, the affected side of the lungs should be superior.
Correct Answer: B
Rationale: The best position for a patient to assume during an admission procedure, particularly for respiratory assessment, is the semi-fowler position at least 30 degrees. In the semi-fowler position, the patient's head and upper body are elevated to a 30-degree angle. This position helps improve lung expansion and oxygenation by reducing pressure on the diaphragm and enhancing chest expansion. It also facilitates breathing and allows for better assessment of respiratory status. Additionally, the semi-fowler position helps prevent aspiration and promotes comfort and relaxation for the patient during the admission procedure.
When the patient was informed about induction, she asks Nurse Aurora what it is all about. which of the following statement by the nurse is correct? Induction is a
- A. local anesthesia used for blocking pain during episiotomy
- B. deliberate initiation of uterine contractions that stimulates labor
- C. medication injected into the subarachnoid space and has a rapid onset of action
- D. procedure per formed by artificial rupture of the membranes
Correct Answer: B
Rationale: Induction is the deliberate initiation of uterine contractions that stimulates labor. It is usually initiated when natural labor is not progressing or is overdue. This process can involve the use of medications or other methods to help the uterus contract and initiate labor. Option B accurately describes induction, making it the correct answer in this case.
A patient expresses frustration with the treatment plan proposed by the healthcare team. What is the most appropriate response from the nurse?
- A. Dismiss the patient's concerns and assure them that the treatment plan is the best option.
- B. Empathize with the patient's frustration and explore their concerns further.
- C. Ignore the patient's frustration and proceed with implementing the treatment plan.
- D. Tell the patient that they have no choice but to follow the treatment plan.
Correct Answer: B
Rationale: The most appropriate response from the nurse when a patient expresses frustration with the treatment plan proposed by the healthcare team is to empathize with the patient's frustration and explore their concerns further. It is important to actively listen to the patient, acknowledge their feelings, and address any questions or uncertainties they may have about the treatment plan. By engaging in open communication and demonstrating empathy, the nurse can foster a therapeutic relationship with the patient and work towards finding a solution that is mutually agreeable and beneficial for the patient's well-being. Dismissing the patient's concerns (Option A) or ignoring their frustration (Option C) can lead to a breakdown in communication and trust, which may ultimately impact the patient's compliance with the treatment plan. Similarly, telling the patient that they have no choice but to follow the treatment plan (Option D) can be perceived as dismissive and confrontational, which is not conducive to promoting patient-centered care.
A patient presents with irritability, muscle weakness, tremors, and weight loss despite increased appetite. Laboratory tests reveal elevated serum thyroid hormone levels and suppressed thyroid-stimulating hormone (TSH) levels. Which endocrine disorder is most likely responsible for these symptoms?
- A. Hyperthyroidism
- B. Hypothyroidism
- C. Diabetes mellitus
- D. Cushing's syndrome
Correct Answer: A
Rationale: The symptoms of irritability, muscle weakness, tremors, weight loss despite increased appetite, along with elevated serum thyroid hormone levels and suppressed TSH levels, are indicative of hyperthyroidism. In hyperthyroidism, the thyroid gland produces an excess amount of thyroid hormone, leading to an overactive metabolism. This results in symptoms such as weight loss, tremors, irritability, and muscle weakness. The elevated levels of thyroid hormone are detected in the laboratory tests, along with low TSH levels due to negative feedback regulation. Therefore, the most likely endocrine disorder responsible for these symptoms is hyperthyroidism.