Nursing textbooks medical-surgical practice questions set 4

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Veins, unlike arteries, are equipped with valves that allow blood to move against the force of gravity. The legs have one-way bicuspid valves that prevent blood from seeping backward as it moves forward by the muscles in our legs pressing on the veins as we walk and increasing venous return. Leg arteries do constrict when walking, which allows the blood to move faster and with more pressure on the tissue, but the greater concern is increasing the flow of venous blood to the heart. Walking increases, not decreases, the heart pumping ability, which increases heart rate and blood pressure and the hearts ability to manage stress. Walking does help the heart adjust to new arteries and may enhance self-esteem, but the patient had an MIthere are no new arteries.

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When using a new adhesive product, the client should patch test it first on nonirritated skin at the inner aspect of the forearm. The most common causes of discomfort are reactions to the adhesive or solvent used to remove it or irritation from leaking fecal drainage. In such cases, the client may experience stinging, tingling, or itching immediately after an appliance change. If a sensation is prolonged or intensified, the client should remove the appliance regardless of whether it has been on for 1 hour or several days. The client should avoid rubbing, which may further irritate skin. If the faceplate is changed too frequently, skin around the stoma may become raw and excoriated secondary to removal of protective layers of epithelium with the faceplate.

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As sepsis progresses, tissues become less perfused and acidotic, compensation begins to fail, and the patient begins to show signs of organ dysfunction. The cardiovascular system also begins to fail, the blood pressure does not respond to fluid resuscitation and vasoactive agents, and signs of end-organ damage are evident (e.g., renal failure, pulmonary failure, hepatic failure). As sepsis progresses to septic shock, the blood pressure drops, and the skin becomes cool, pale, and mottled. Temperature may be normal or below normal. Heart and respiratory rates remain rapid. Urine production ceases, and multiple organ dysfunction progressing to death occurs. Adventitious lung sounds occur throughout the lung fields, not just in the upper fields of the lungs.

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The initial intervention would be to place a medical alert band on the patient, then tag the chart. The charge nurse and the surgeon should be notified in the event the surgeon wants to order a preoperative prophylactic treatment. The patient will need to go to the designated operating room for patients with latex allergies, or be the first case in the operating room. Even though patients allergic to latex are frequently allergic to bananas, notifying the kitchen the patient is allergic to bananas is not a necessary initial action. The patient should be fasting. It is important to tag the chart, but it is more crucial to attach a medical alert band to the patient, in case the chart is misplaced. There is no need to place the patient in an isolation room.

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Clients with aplastic anemia experience all the typical characteristics of anemia (weakness and fatigue). In addition, they have frequent opportunistic infections plus coagulation abnormalities that are manifested by unusual bleeding, small skin hemorrhages called petechiae, and ecchymoses (bruises). The spleen becomes enlarged with an accumulation of the client's blood cells destroyed by lymphocytes that failed to recognize them as normal cells, or with an accumulation of dead transfused blood cells. The blood cell count shows insufficient numbers of blood cells. A bone marrow aspiration confirms that the production of stem cells is suppressed. This scenario does not describe a client with pernicious anemia, iron-deficiency anemia, or agranulocytosis.

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Although the exact cause of venous thrombosis remains unclear, three factors, known as Virchows triad, are believed to play a significant role in its development: stasis of blood (venous stasis), vessel wall injury, and altered blood coagulation. In this womans case, she has venous stasis from immobility, vessel wall injury from PAD, and altered blood coagulation from HF. The cause of aoritis is unknown, but it has no direct connection to HF, PAD, or mobility issues. The greatest risk factors for thoracic aortic aneurysm are atherosclerosis and hypertension; there is no direct connection to HF, PAD, or mobility issues. Raynauds disease is a disorder that involves spasms of blood vessels and, again, no direct connection to HF, PAD, or mobility issues.

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In this scenario, the nurse will assume the role of educator by explaining information provided during the client/health care provider discussion. The nurse as educator provides client teaching regarding the plan of care, medications, or prescribed tests and procedures. The nurse as a caregiver performs health-related activities that the client is unable to perform independently due to illness. The nurse as a collaborator works with others to achieve a common goal, such as sharing or exchanging information with other health care professionals (dietitians, physical therapists, or respiratory therapists). The nurse as a delegator assigns tasks to someone else such as another nurse, a nursing assistant, or other unlicensed assistive personnel (UAP).

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Many clients with CFS report having had a recent illness with flulike symptoms or an upper respiratory infection. Despite having been uncomfortable, most clients do not describe their initial symptoms as being extraordinarily severe. Severe, ongoing fatigue lasts for at least 6 months without any explanation. Even though the fatigue is constant, it worsens after physical activity. The fatigue is so debilitating that it usually interferes with a person's ability to work in or outside the home. Rheumatoid arthritis and ulcerative colitis are autoimmune disorders with symptoms that are more specific than CFS and can be diagnosed with diagnostic testing and laboratory studies. The symptoms that the client is having are not characteristic of the flu.

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The PCA prescription can be set for a basal rate for a continuous infusion of pain medication. Additional doses can be administered by the patient, parent, or nurse as necessary. Although the goal of PCA is to have effective pain relief, a pain-free state may not be possible. With a 6-year-old child, the parents and nurse must assess the child to ensure that adequate medication is being given because the child may not understand the concept of pushing a button. Evidence-based practice suggests that effective analgesia can be obtained with the parents and nurse giving boluses as necessary. The prescription for the PCA includes how much medication can be given in a defined period. Monitoring every 1 to 2 hours for patient response is sufficient.

Correct answer:

The hypothalamus regulates body temperature, so damage from a head injury disrupts thermoregulation, potentially causing hypo- or hyperthermia. Monitoring temperature (B) is critical to detect these shifts, which can indicate injury severity or complications like fever from inflammation. Pulse (A) reflects cardiac response but isn't directly hypothalamic. Respirations (C) may change secondary to brain injury but aren't primarily hypothalamic. Blood pressure (D) can fluctuate with intracranial pressure, yet temperature is the most directly affected vital sign here. Choice B is correct as it aligns with the hypothalamus's role in maintaining thermal homeostasis, a priority in neuro nursing to prevent further brain damage or systemic issues.