Nursing textbooks medical-surgical practice questions set 7

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This response indicates the nurse's willingness to assist the patient with the decision-making process without imposing the nurse's values or opinions. It is not appropriate to say that it is not the nurse's decision to make as this would close the conversation and indicates that the nurse is not willing to help the patient with the decision about treatment. Because treatment decisions for breast cancer do need to be made relatively quickly, it is not alright to tell the patient that the decision does not need to be made rapidly. Since the nurse's values and situation are not the same as the patient's, imposing the nurse's opinions during this emotionally vulnerable time is not appropriate.

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Hypostatic pulmonary congestion, caused by a weakened cardiovascular system that permits stagnation of secretions at lung bases, may develop; this condition occurs most frequently in elderly patients who are not mobilized effectively. The symptoms are often vague, with perhaps a slight elevation of temperature, pulse, and respiratory rate, as well as a cough. Physical examination reveals dullness and crackles at the base of the lungs. If the condition progresses, then the outcome may be fatal. A pulmonary embolism does not have this presentation and hypervolemia is unlikely due to the patients low fluid intake. Malignant hyperthermia occurs concurrent with the administration of anesthetic.

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Boarding homes usually are small homes with individual rooms where residents pay for room and board and minimal nursing services. Residents often share rooms, have a common dining area for all meals, and also oversee employment for disabled adults and provide a stable environment for those who cannot live independently. Congregate housing provides independent living for seniors or disabled adults who need minimal to no assistance. Long-term care facilities are for clients who require long-term wound care or ventilator support or who have other conditions that are potentially unstable but do not have rapid changes. Acute care facilities are for those clients who are of high illness acuity.

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Antibodies are chemical substances that destroy foreign agents such as microorganisms, which decrease the risk of infection at the site. A cell-mediated response occurs when T cells survey proteins in the body, actively analyze the surface features, and respond to those that differ from the host by directly attacking the invading antigen such as an organ transplant. Memory cells convert to plasma cells on reexposure to a specific antigen. When activated, B cells accumulate in lymphoid tissues and result in swollen lymph nodes. Passive immunity develops when ready-made antibodies are given to a susceptible person. They provide immediate but short-lived protection from an invading antigen.

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Anaphylactic shock is a severe allergic reaction that follows exposure to a substance to which a person is extremely sensitive (see Ch. 34). Common allergic substances include bee venom, latex, fish, nuts, and penicillin. The body's immune response to the allergic substance causes mast cells in the connective tissues, bronchi, and gastrointestinal tract to release histamine and other chemicals. The results are vasodilatation, increased capillary permeability accompanied by swelling of the airway and subcutaneous tissues, hypotension, and hives or an itchy rash. Cardiogenic shock, neurogenic shock, and obstructive shock would not begin with vasodilation, swelling of the airway, and hives.

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If the patient makes any statement about the drug, the nurse needs to hold the drug and investigate the patient's statement, double checking the chart and the order and obtaining clarification and/or confirmation from the prescriber. It may be that the dosage or manufacturer has changed and that is what makes the pill look different. It is always important to err on the side of caution. Telling the patient that the pill is the same or that it is from a different manufacturer may be true, but the nurse needs to confirm that before giving it to the patient. Repeating the patient's statement and then asking him if he is sure is inappropriate because it implies that the patient is incorrect.

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Free radicals are natural by-products of many normal cellular processes and are also created under the influence of environmental factors such as smog, tobacco smoke, and radiation. Numerous natural protective mechanisms are in place to prevent oxidative damage. Recent research has focused on the roles of various antioxidants, including vitamins C and E, in slowing down the oxidative process and, ultimately, the aging process. The somatic mutation theory focuses on spontaneous mutations. The crosslinking theory is based upon lipids, proteins, CHO, and nucleic acid reactions. The telomere-telomerase depletion theory focuses on the loss of telomeres, repeated sequences at the ends of DNA.

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An expected outcome for the client with hypovolemic anemia is to monitor to detect hypoxemia and manage and minimize inadequate oxygenation. The oxygen saturation should be monitored to measure the percentage of oxygen bound to hemoglobin. The nurse should report a sustained oxygen saturation value below 90%. Give oxygen per nasal cannula or simple mask to maintain oxygen saturation at or above 90%. It is important to administer the oxygen first and then contact the charge nurse to alert them. It is not necessary at this time if the client is not in respiratory distress to intubate the client. Placing the client in the supine position would decrease the oxygen saturation level further.

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This response is consistent with the Canadian Nurses Association (CNA) definition of nursing. Registered nurses are self-regulated health care professionals who work autonomously and in collaboration with others. RNs enable individuals, families, groups, communities and populations to achieve their optimal level of health. RNs coordinate health care, deliver direct services, and support patients in their self-care decisions and actions in situations of health, illness, injury, and disability in all stages of life. The other responses describe some of the dependent and collaborative functions of the nursing role but do not accurately describe the nurse's role in the health care system.

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To see whether a client is tolerating activity, vital signs are measured before, during, and after the activity. If the client is not tolerating activity, heart rate may increase more than 20 beats/min, blood pressure may increase more than 20 mmHg, or the client may experience symptoms indicating intolerance. Body image assessment is not necessary before basic activities are performed. Self-care abilities and ability to use assistive or adaptive devices are important when planning rehabilitation activities but do not provide essential information about activity tolerance. Electrocardiography is not typically used to monitor clients in a rehabilitation setting for activity tolerance.