Nokea
What best evaluates Mrs. West’s situation with wound separation and purulent drainage?
- A. This response is consistent with the inflammatory process
- B. Some drainage is to be expected from a surgical incision
- C. This response indicates a break in sterile technique has occurred
- D. This wound is healing by first intention
Correct Answer: A
Rationale: Inflammatory signs suggest infection, requiring further evaluation and treatment.
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For each of the nursing diagnoses listed, identify at least two normal expected physiologic changes related to aging that could be etiologic factors of the diagnosis.
- A. Imbalanced nutrition: less than body requirements
- B. Activity intolerance
- C. Risk for injury
- D. Urge urinary incontinence
Correct Answer: A
Rationale: Aging-related changes include decreased appetite, reduced muscle mass, impaired balance, and increased bladder sensitivity—all contributing to various nursing diagnoses.
Mr. Jones has a scleral buckling procedure for repair of his retinal detachment. He states that he can see quite well now and wants to know if his vision will continue to improve. Which reply by the nurse would be most appropriate?
- A. It will be important to monitor your progress over the next 2 months.'
- B. Your eye should be fine provided that you do everything your doctor has told you.'
- C. There is no way of predicting whether or not this will recur.'
- D. You seem worried that this condition may recur.'
Correct Answer: A
Rationale: Monitoring progress over time is essential after retinal surgery, as visual improvement varies and requires ongoing assessment to ensure optimal outcomes.
Denise is recovering from an open cholecystectomy. You know that because of the location of the surgery, she has an increased chance of postoperative
- A. Myocardial infarction.
- B. Respiratory complications.
Correct Answer: B
Rationale: Abdominal surgeries can increase the risk of respiratory complications due to reduced lung expansion.
Who should ideally do discharge planning?
- A. Practical nurse
- B. Professional nurse and the patient
- C. Patient and his family
- D. Public health nurse
Correct Answer: B
Rationale: Collaboration between the professional nurse and the patient ensures personalized and effective discharge planning.
While caring for a client who was injured in a motor-vehicle crash and reports dyspnea and severe pain, a nurse in the emergency department notes that the client's chest moves inward during inspiration and bulges out during expiration. The nurse should identify this finding as which of the following?
- A. Atelectasis
- B. Flail chest
- C. Hemothorax
- D. Pneumothorax
Correct Answer: B
Rationale: The correct answer is B: Flail chest. Flail chest occurs when a segment of the rib cage is detached from the rest of the chest wall, causing paradoxical chest movement. In this case, the inward movement during inspiration and outward bulging during expiration are classic signs of flail chest, as the detached segment moves in the opposite direction of the rest of the chest wall. Atelectasis (choice A) refers to collapsed lung tissue, not paradoxical chest movement. Hemothorax (choice C) is the accumulation of blood in the pleural space, which does not cause paradoxical chest movement. Pneumothorax (choice D) is the presence of air in the pleural space, which can cause chest pain and dyspnea but does not result in paradoxical chest movement.