Nokea
What nursing diagnosis would be MOST appropriate for a client admitted with heart failure?
- A. Risk for denial
- B. Ineffective tissue perfusion
- C. Impaired gas exchange
- D. Acute pain
Correct Answer: B
Rationale: Heart failure is a condition in which the heart is unable to pump enough blood to meet the body's need for oxygen and nutrients. Ineffective tissue perfusion is a relevant nursing diagnosis for a client with heart failure because the heart's inability to effectively pump blood can lead to poor perfusion of tissues and organs, resulting in inadequate oxygen and nutrient delivery to cells. This can lead to symptoms such as fatigue, dyspnea, and edema, which are common in individuals with heart failure. By addressing ineffective tissue perfusion, nurses can focus on interventions to improve cardiac output and optimize tissue perfusion, ultimately improving the client's overall condition.
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Which of the following actions is indicated in the management of a patient with an open chest wound (sucking chest wound)?
- A. Applying a sterile dressing and occlusive dressing.
- B. Administering supplemental oxygen.
- C. Providing reassurance and emotional support.
- D. Elevating the patient's legs to improve venous return.
Correct Answer: A
Rationale: An open chest wound, also known as a sucking chest wound, can lead to a collapsed lung and respiratory distress. Immediate management involves sealing the wound to prevent air from entering the pleural space and further compromising the patient's respiratory function. Applying a sterile dressing over the wound helps to prevent contamination and occluding the wound with an airtight covering, such as an occlusive dressing, can effectively reduce the risk of a tension pneumothorax, a serious complication that can arise from a sucking chest wound. These interventions help to stabilize the patient's condition and improve the chances of a successful recovery. Administering supplemental oxygen, though beneficial, would be secondary to the primary management of sealing the chest wound. Providing emotional support is important but addressing the physical emergency takes precedence. Elevating the patient's legs would not be appropriate in managing an open chest wound.
A patient presents with sudden-onset severe headache, altered mental status, and focal neurological deficits. Imaging reveals a hemorrhagic lesion within the right basal ganglia. Which of the following neurological conditions is most likely responsible for these symptoms?
- A. Ischemic stroke
- B. Subarachnoid hemorrhage
- C. Intracerebral hemorrhage
- D. Transient ischemic attack (TIA)
Correct Answer: C
Rationale: Intracerebral hemorrhage occurs when there is bleeding directly into the brain tissue, often due to conditions such as hypertension or vascular malformations. The sudden-onset severe headache, altered mental status, and focal neurological deficits described in the patient are typical symptoms of an intracerebral hemorrhage. The location of the hemorrhagic lesion within the right basal ganglia corresponds to the clinical presentation. Ischemic stroke, subarachnoid hemorrhage, and transient ischemic attack (TIA) typically have different presentations and imaging findings compared to an intracerebral hemorrhage. Therefore, in this scenario, intracerebral hemorrhage is the most likely cause of the patient's symptoms.
A patient presents with muscle weakness, fatigue, constipation, and hyperpigmentation of the skin. Laboratory tests reveal low serum cortisol levels and elevated adrenocorticotropic hormone (ACTH) levels. Which endocrine disorder is most likely responsible for these symptoms?
- A. Hyperthyroidism
- B. Hypothyroidism
- C. Diabetes mellitus
- D. Addison's disease
Correct Answer: D
Rationale: The symptoms described - muscle weakness, fatigue, constipation, hyperpigmentation of the skin, low serum cortisol levels, and elevated ACTH levels - are classic findings in Addison's disease. Addison's disease is a primary adrenal insufficiency characterized by the insufficient production of cortisol and, to some extent, aldosterone. The low cortisol levels result in symptoms such as muscle weakness, fatigue, and skin hyperpigmentation due to increased levels of ACTH stimulating melanin production. In contrast, in conditions like hyperthyroidism, hypothyroidism, and diabetes mellitus, the symptoms and laboratory findings would not fully align with those described in the patient in this scenario.
What IMMEDIATE danger should the nurse anticipate post Transurethral Resection of the Prostate (TURP)?
- A. Infection
- B. Thrombosis
- C. Bleeding
- D. Shock
Correct Answer: C
Rationale: Post Transurethral Resection of the Prostate (TURP), the immediate danger that the nurse should anticipate is bleeding. TURP is a surgical procedure that involves removing portions of the prostate gland through the urethra. Due to the nature of the surgery and the rich blood supply to the prostate, bleeding is a common complication post-TURP. Excessive bleeding can lead to hypovolemic shock, which is a life-threatening condition. Therefore, monitoring for signs of bleeding, such as blood in the urine, drop in hematocrit levels, hypotension, tachycardia, and signs of hypovolemic shock, is crucial to prevent any serious complications. Proper assessment, monitoring, and timely intervention are essential in managing post-TURP bleeding and preventing adverse outcomes.
Friendly but professional overtures have finally made Marlene open up her circumstances to the nurse, including their financial difficulty. What has been established at this time?
- A. Beginning of a friendship
- B. Trusting relationship with the nurse
- C. A lifelong commitment
- D. A dire need for financial help
Correct Answer: B
Rationale: Marlene opening up to the nurse about their financial difficulty indicates that she feels comfortable enough to share personal information with the nurse. This signals the establishment of a trusting relationship between Marlene and the nurse, as Marlene feels safe and supported enough to disclose sensitive information. Building trust is a crucial aspect of any professional relationship, especially in healthcare settings, as it fosters open communication, encourages honesty, and ultimately leads to better outcomes for the patient. It is an essential foundation for providing effective care and support to individuals in need.