Nokea
Which patient needs attention first?
- A. An elderly person complains of dizziness and syncope after standing in the sun for several hours to view a parade
- B. A marathon runner complains of severe leg cramps and nausea. Tachycardia, diaphoresis, pallor, and weakness are observed
- C. A previously healthy homemaker reports broken air conditioner for days. Tachypnea, hypotension, fatigue, and profuse diaphoresis are observed
- D. A homeless person, poor historian, presents with altered mental status, poor muscle coordination, and hot, dry, ashen skin. Duration of exposure is unknown
Correct Answer: D
Rationale: Hot, dry skin and altered mental status suggest heat stroke, a medical emergency requiring immediate cooling measures.
You may also like to solve these questions
For each of the following body systems, identify three physical manifestations that the nurse would expect to see in a patient approaching death.
- A. Respiratory: Cheyne-Stokes respirations
- B. Skin: Mottling
- C. Gastrointestinal: Loss of appetite
- D. Musculoskeletal: Weakness
Correct Answer:
Rationale:
Mrs. Blakely had an intracapsular extraction yesterday. Early this morning she complained of eye pain and nausea after breakfast while continuing to complain of eye pain. Your analysis of the situation is that Mrs. Blakely is
- A. unable to tolerate a regular diet this soon postoperatively
- B. allergic to the pain medication
- C. experiencing increased intraocular pressure
- D. exhibiting symptoms of postoperative infection
Correct Answer: C
Rationale: Severe eye pain accompanied by nausea following cataract surgery suggests elevated intraocular pressure, which must be addressed promptly to prevent complications.
The nurse is assessing a client with delayed wound healing. Which of the following risk factors is most important in this situation?
- A. Glucose level of 120 mg/dl.
- B. History of myocardial infarction.
- C. Long term steroid usage.
- D. Diet high in carbohydrates.
Correct Answer: C
Rationale: Steroids impair wound healing by affecting collagen formation and immune response.
The patient asks you what the clip on his finger is for. The best response is
- A. This is a cardiac monitor that alerts us to any arrhythmia that you might experience during the night.
- B. This measures your temperature.
- C. This is pulse oximetry and is used to give us an idea of how much oxygen is in your blood.
- D. This tells us the number of red blood cells you have. These cells provide oxygen throughout your body.
Correct Answer: C
Rationale: Pulse oximetry measures oxygen saturation in the blood.
Sue is diagnosed with congestive heart failure. What medication would you expect to administer to strengthen myocardial contractility?
- A. Nitroprusside.
- B. Digoxin.
- C. Nitroglycerine ointment.
- D. Furosemide.
Correct Answer: B
Rationale: Digoxin enhances myocardial contractility in CHF.