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The nurse will monitor J.E. for the following signs and symptoms:
- A. Change in the levei of consciousness, tachypnea, tachycardia, petechiae
- B. Onset of chest pain, tachycardia, diaphoresis, nausea and vomiting
- C. Loss of consciousness, bradycardia, petechiae, and severe leg pain
- D. Change in leve! of consciousness, bradycardia, chest pain and oliguria
Correct Answer: A
Rationale: The signs and symptoms mentioned in option A are indicative of potential complications that may occur in a patient being monitored by a nurse.
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A few hours before the patient was admitted at the hospital, he complained of fever, nausea and vomiting, and vague abdominal pain. The doctor examined the patient as a case of acute appendicitis and prepared for appendectomy. The nurse anticipates that this type of surgery is classified as:
- A. emergency
- B. urgent
- C. elective
- D. required
Correct Answer: A
Rationale: Appendectomy as a treatment for acute appendicitis is classified as an emergency surgery. Acute appendicitis is considered a medical emergency that requires prompt surgical intervention to prevent complications such as a ruptured appendix, which can lead to peritonitis, a life-threatening condition. In emergency situations, surgery must be done urgently to address the immediate threat to the patient's health. This is in contrast to elective surgeries, which are typically scheduled in advance and do not require immediate attention. In the case described, the patient's symptoms of fever, nausea, vomiting, and vague abdominal pain suggest an acute presentation that necessitates urgent surgical intervention, making it an emergency appendectomy.
In the presence of coma or unconsciousness, the major therapeutic measure includes:
- A. Maintenance of a clear airway
- B. Good nursing care
- C. Retention of catheter
- D. All of the above
Correct Answer: A
Rationale: In the presence of coma or unconsciousness, maintaining a clear airway is the major therapeutic measure to ensure adequate breathing and oxygenation. A clear airway is vital for the patient's survival and should be the priority to prevent respiratory distress or failure. Providing good nursing care is important for overall patient well-being, but ensuring a clear airway is crucial for immediate life support. Retention of a catheter is not a major therapeutic measure in the context of coma or unconsciousness unless specifically indicated for monitoring or treatment of underlying conditions. Therefore, the most critical intervention in this scenario is the maintenance of a clear airway.
Which of the following assessment findings would suggest to the home health nurse that the patient is developing congestive heart failure?
- A. orthopnea
- B. fever
- C. weight loss
- D. calf pain A1 PASSERS TRAINING, RESEARCH, REVIEW & DEVELOPMENT COMPANY MEDICAL SURGICAL NURSING SET O
Correct Answer: A
Rationale: Orthopnea is a common symptom of congestive heart failure. It is defined as difficulty in breathing when lying flat, which improves when sitting up or standing. This occurs due to the redistribution of blood in the body when changing positions. As fluid accumulates in the lungs in congestive heart failure, lying down increases pressure on the chest and impairs breathing. Therefore, orthopnea is a significant assessment finding that would suggest to the home health nurse that the patient is developing congestive heart failure. Fever, weight loss, and calf pain are not typically associated with congestive heart failure.
diagnosis of congenital heart disease usually through
- A. cardiac catheterization.
- B. chest x-ray and ECG.
- C. echocardiogram.
- D. all of the above.
Correct Answer: C
Rationale: The diagnosis of congenital heart disease is most commonly done through an echocardiogram, which is a non-invasive test that uses sound waves to create images of the heart's structure and function. This imaging technique allows healthcare providers to visualize any abnormalities in the heart's structure and how it is functioning. While cardiac catheterization and chest x-ray with ECG can also provide valuable information, an echocardiogram is the primary diagnostic tool for identifying congenital heart defects due to its accuracy, safety, and non-invasiveness.
A parent asks the nurse "at what age do most infants begin to fear strangers?" The nurse should give which response?
- A. 2 months
- B. 4 months
- C. 6 months
- D. 12 months
Correct Answer: C
Rationale: Most infants begin to exhibit fear or stranger anxiety around 6 months of age. This is a normal developmental stage where infants become more aware of their surroundings and become wary of unfamiliar people. Infants may become anxious or cry when approached by strangers, showing that they prefer familiar faces like parents or caregivers. This behavior typically peaks between 6 to 9 months and gradually decreases as the child grows older and gains more social experience.