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Which of the following patients should the nurse monitors because of increased risk for surgical complications?
- A. 25-year old with appendicitis
- B. patient 5'3" in height, weight 180 lbs
- C. 12-year old with fractured knee
- D. 17-year old with gallstone
Correct Answer: B
Rationale: The patient who is 5'3" in height and weighs 180 lbs is considered obese based on their body mass index (BMI). Obesity is a significant risk factor for surgical complications such as wound infections, blood clots, and respiratory issues. In obese patients, surgical procedures can be more challenging due to difficulties in accessing and visualizing surgical sites, longer surgery times, and increased stress on the body's organs. Therefore, this patient should be closely monitored for potential surgical complications.
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A 72-year-old chemist has left lower lobe pneumonia. His nurse checks his oxygen saturation and the result is 86%. Which of the ff. actions by the nurse is best?
- A. Call the physician for an order for oxygen.
- B. No action necessary; this is a normal SaO
Correct Answer: A
Rationale: An oxygen saturation (SaO2) level of 86% is significantly below the normal range of 95-100%. This indicates hypoxemia, which means the body is not getting enough oxygen. In a patient with pneumonia, low oxygen saturation can lead to further respiratory compromise and potential organ damage. Therefore, it is essential for the nurse to notify the physician promptly to obtain an order for supplemental oxygen to correct the hypoxemia and improve the patient's oxygen saturation levels. Delay in addressing low oxygen levels can have serious consequences for the patient's health and recovery.
The nurse is teaching nursing students about childhood skin lesions. Which is an elevated, circumscribed skin lesion that is less than 1 cm in diameter and filled with serous fluid?
- A. Cyst
- B. Papule
- C. Pustule
- D. Vesicle
Correct Answer: D
Rationale: A vesicle is an elevated, circumscribed skin lesion that is less than 1 cm in diameter and filled with serous fluid. Serous fluid is a clear, watery fluid that can accumulate within the vesicle. Vesicles are commonly seen in conditions such as herpes simplex virus infections (cold sores) and contact dermatitis. It is important for nursing students to understand the characteristics of different skin lesions to accurately assess and provide appropriate care for patients.
Childhood primary brain stem tumors are a heterogeneous group of tumors; the outcome usually depends on the tumor location. Which tumor, depending on the site of tumor, carries the worst prognosis?
- A. focal dorsally exophytic
- B. cervicomedullary diffuse intrinsic
- C. none of the above
- D. diffuse intrinsic
Correct Answer: D
Rationale: Diffuse intrinsic pontine gliomas (DIPG) have the worst prognosis among brainstem tumors.
A client is diagnosed with diabetes mellitus. Which assessment finding best supports a nursing diagnosis of Ineffective individual coping related to diabetes mellitus?
- A. Recent weight gain of 20 lb
- B. Skipping insulin doses during illness
- C. Failure to monitor blood glucose
- D. Crying whenever diabetes is levels mentioned
Correct Answer: D
Rationale: Crying whenever diabetes is mentioned indicates a maladaptive coping mechanism, which can be a sign of ineffective individual coping related to diabetes mellitus. Coping with a chronic condition like diabetes can be overwhelming, and excessive emotional distress may hinder the client's ability to effectively manage their disease. It is important for the nurse to identify maladaptive coping strategies in order to provide appropriate interventions and support for the client.
Which of the following BP changes alerts the nurse to increasing ICP, and should be reported immediately?
- A. Gradual increase
- B. Widening pulse pressure
- C. Rapid drop followed by gradual increase
- D. Rapid fluctuations
Correct Answer: B
Rationale: Widening pulse pressure is indicative of increasing intracranial pressure (ICP) and must be reported immediately. Pulse pressure is calculated by subtracting the diastolic blood pressure from the systolic blood pressure. An increasing pulse pressure can suggest a rise in ICP due to factors like cerebral edema or hemorrhage. This change indicates increased pressure exerted on blood vessels within the brain, potentially leading to serious consequences like brain herniation. Thus, recognizing and promptly reporting a widening pulse pressure is crucial to prevent further complications and enable appropriate interventions for the patient.