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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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After several days in the hospital, the physician ordered the patient to be discharged. Which of the following is a PRIORITY restriction that you should emphasize when he goes home?
- A. Stool softener to induce bowel elimination.
- B. Driving if not using narcotic drug.
- C. Take shower even if ´still with surgical drain.
- D. Lifting of objects not more than 10 lbs.
Correct Answer: D
Rationale: The priority restriction that should be emphasized when the patient is discharged from the hospital is the lifting of objects not more than 10 lbs. This is important to prevent any strain on the body, especially if the patient is still recovering or weak from their hospitalization. Lifting heavy objects can lead to complications, injuries, or setbacks in the recovery process. It is essential for the patient to follow this restriction to promote healing and avoid any further health issues.
A patient expresses concerns about the potential side effects of a prescribed medication. What is the nurse's best approach to address these concerns?
- A. Dismiss the patient's concerns and reassure them that side effects are unlikely.
- B. Provide the patient with accurate information about potential side effects and management strategies.
- C. Ignore the patient's concerns and focus solely on administering the medication.
- D. Tell the patient that side effects are common and unavoidable.
Correct Answer: B
Rationale: The nurse's best approach to address a patient's concerns about the potential side effects of a prescribed medication is to provide the patient with accurate information about potential side effects and management strategies. It is important for the nurse to acknowledge the patient's concerns, listen attentively, and offer clear explanations to help alleviate any fears or uncertainties. Providing accurate information can empower the patient to make informed decisions about their healthcare and feel more confident in taking the prescribed medication. Dismissing or ignoring the patient's concerns can lead to mistrust and non-adherence to the treatment plan. It is essential for the nurse to prioritize open communication and patient education to ensure the patient's well-being and compliance with the prescribed medication regimen.
A nurse ________.
- A. Has the freedom to do what he likes and responsibilities.
- B. Is obliged to avoid what is wrong and do what is good.
- C. Is a person capable of knowing what is right or wrong
- D. Should have a sense of accountability for his actions
Correct Answer: D
Rationale: A nurse should have a sense of accountability for his actions. This means taking responsibility for one's decisions and behaviors while working in the healthcare setting. Accountability ensures that the nurse is aware of the consequences of his actions and is willing to accept ownership and follow through on commitments. It is a critical aspect of nursing practice as it helps maintain professional standards, promote patient safety, and uphold trust and integrity within the profession. Nurses are entrusted with the well-being of their patients, so being accountable for their actions is essential in providing high-quality care and maintaining ethical standards.
A few days later, the patient comes into the emergency department via ambulance stretcher and reveals a work-up of blood sugar level at 800mg/dl, ketones are absent in the urine, she is dehydrated, and has an altered mental status. Based on the data, t he patient is most likely suferring from what specifi medical condition?
- A. Hyperosmolar nonketotic coma (HNKC)
- B. Diabetic retinopathy
- C. Acute renal failure
- D. Diabetic ketoacidosis (DKA)
Correct Answer: A
Rationale: The patient's presentation with a blood sugar level of 800mg/dL, absence of ketones in the urine, dehydration, and altered mental status points towards Hyperosmolar nonketotic coma (HNKC). HNKC typically occurs in patients with Type 2 diabetes and is characterized by extremely high blood glucose levels (hyperglycemia) without significant ketosis. The absence of ketones in the urine distinguishes HNKC from Diabetic ketoacidosis (DKA). Patients with HNKC often present with severe dehydration, altered mental status, and hyperosmolarity. It is crucial to address the underlying cause of the hyperglycemia, correct dehydration, and normalize blood glucose levels promptly in the management of HNKC.
An 80-years-old male, admitted for emergency suturing of the forehead sustained from accident fall while gardening under local sedation us received in the ward. Which nursing intervention is APPROPRIATE to facilitate effective communication with this patient?
- A. Talk to patient when ful1y awake and inform him and family events which may occur post-surgery .
- B. Provide the patient with instruction materials about discharge.
- C. Tell the patient, "You are fine nothing to worry."
- D. Ask the patient, "Do you know where you are?''
Correct Answer: A
Rationale: Option A is the most appropriate nursing intervention to facilitate effective communication with the 80-year-old male patient. This approach involves waiting for the patient to be fully awake before discussing important information about the surgery and potential post-surgery events with both the patient and family. This allows the patient to fully comprehend the information provided and ask any necessary questions. Effective communication is crucial in promoting patient understanding and cooperation, especially in older adults who may require additional time to process information due to factors such as age-related cognitive changes. It is important to ensure that the patient receives clear and accurate information to support their recovery process and reduce anxiety.