While caring for an unconscious patient, the nurse discovers a stage 2 pressure ulcer on the patient’s heel. During care of the ulcer, what is the nurse’s understanding of the patient’s perception of pain?
- A. The patient will have a behavioral response if pain is perceived.
- B. The area should be treated as a painful lesion, using gentle cleansing and dressing.
- C. The area can be thoroughly scrubbed because the patient is not able to perceive pain.
- D. All nociceptive stimuli that are transmitted to the brain result in the perception of pain.
Correct Answer: B
Rationale: The correct answer is B. Even in unconscious patients, the area should be treated gently to avoid exacerbating potential pain.
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For a patient with osteogenic sarcoma, you would be particularly vigilant for elevations in which laboratory value?
- A. Sodium.
- B. Calcium.
- C. Potassium.
- D. Hematocrit.
Correct Answer: B
Rationale: Elevated calcium levels are commonly associated with osteogenic sarcoma due to bone destruction and release of calcium into the bloodstream.
Give an example of a sensitive way to ask a patient each of the following questions.
- A. Is the patient on antihypertensive medication having a side effect of impotence?
- B. Has the patient with a history of alcoholism had recent alcohol intake?
- C. Who are the sexual contacts of a patient with gonorrhea?
- D. Does the patient skip taking medications because they cost too much?
Correct Answer: B
Rationale: N/A
A client continually repeats phrases that others have just said. The nurse recognizes this behavior as:
- A. Autistic.
- B. Ecopraxic.
- C. Echolalic.
- D. Catatonic.
Correct Answer: C
Rationale: Echolalia is the repetition of words or phrases heard from others.
What type of shock is the client experiencing if there is no urine return after inserting a Foley catheter?
- A. Decreased blood pressure
- B. Increased heart rate
- C. Fluid retention
- D. Muscle cramps
Correct Answer: A
Rationale: Decreased blood pressure is a primary symptom in fluid imbalance as a result of inadequate circulating volume, leading to hypotension and possible shock.
What is the priority nursing action for this patient?
- A. Obtain an order for a blood alcohol level
- B. Contact the family to obtain additional history and baseline information
- C. Administer naloxone (Narcan) 2-4 mg as ordered
- D. Administer IV fluid support with supplemental thiamine as ordered
Correct Answer: D
Rationale: Fluid support and thiamine administration address potential dehydration and nutritional deficits in intoxicated patients.