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B. Elevating the head of the bed 30-45 degrees
Rationale: To facilitate venous drainage and avoid jugular compression, the nurse
should
elevate the head of the bed 30-45 degrees. Option A is incorrect because patients
with increased ICP poorly tolerate suctioning and shouldn't be suctioned on a regular
basis. Option C is incorrect because turning from side to side increases the risk of
jugular compression and rises in ICP. Option D is incorrect because the room should
be kept quiet and dimly lit.
Give this one a try later!
, The nurse is caring for a comatose patient who has suffered a closed head
injury. Which intervention
should the nurse implement to prevent increases in ICP?
A. Suctioning the airway every hour and as needed
B. Elevating the head of the bed 30 to 45 degrees
C. Turning the patient and changing his position every 2 hours
D. Maintaining a well-lit room
2) www.cancer.gov.
Rationale: When a patient asks about researching information on the internet, the
patient should be instructed to look at reliable sites. Sites that are most reliable are
those sponsored by the government (.gov).
Give this one a try later!
Charles Haverford is diagnosed with prostate cancer and is to have a
radical prostatectomy.
Mr. Haverford has been researching his diagnosis and now asks the nurse
to recommend a reliable web source for accurate prostate cancer
information. The nurse should identify which of these websites as most
reliable?
1) www.wikipedia.org.
2) www.cancer.gov.
3) www.caringbridge.org.
4) www.google.com.
A. The medial lower leg and ankle
Rationale: A venous ulcer is typically found on the medial lower leg and ankle.
A diabetic ulcer is usually found on the plantar aspect of the foot (Option B) or under
the heels (Option D).
A pressure ulcer is usually found on a bony prominence (Option C).
,Give this one a try later!
Where is a venous ulcer typically found on a patient?
A. The medial lower leg and ankle
B. The plantar aspect of foot
C. On a bony prominence
D. Under the heels
2. Paternalism.
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A patient's family does not know the patient's end-of-life care preferences,
but assumes that they know what is best for the patient under the
circumstances. This assumption reflects:
1. Justice.
2. Paternalism.
3. Pragmatism.
4. Veracity.
D. Total lymphocyte count of 1,900 mL
Rationale: A total lymphocyte count greater than 1,800 mL indicates adequate
nutrition.
Options A, B, and C are incorrect because these laboratory values indicate poor
nutrition.
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, The nurse is assessing the laboratory values of a patient with an abdominal
wound healing by secondary
intention. Which of the following laboratory values indicates that the patient
is receiving adequate nutrition?
A. Serum albumin level of 2.5 g/dL
B. Prealbumin level of 12 mg/dL
C. Transferrin level of 190 mg/dL
D. Total lymphocyte count of 1,900 mL
C. The dressing should be allowed to dry before it's removed.
Rationale: A wet-to-dry dressing should be allowed to dry and adhere to the wound
before being removed. The goal is to debride the wound as the dressing is removed.
Option A is incorrect because the wet-to-dry dressing isn't applied to keep a wound
moist; a moist saline dressing is applied to keep a wound moist.
Option B is incorrect because tightly packing a wound damages the tissues.
Option D is incorrect because a wet-to-dry dressing should be covered with a dry
gauze dressing, not a plastic sheet-type dressing.
Give this one a try later!
The nurse is providing care for a patient who has a sacral pressure ulcer
with a wet-to-dry dressing. Which
guideline is appropriate when caring for a patient with a wet-to-dry
dressing?
A. The wound should remain moist from the dressing.
B. The wet-to-dry dressing should be tightly packed into the wound.
C. The dressing should be allowed to dry before it's removed.
D. A plastic sheet-type dressing should cover the wet dressing
D. Erickson's psychosocial development model focuses on conflicts at each stage of
the lifespan and the virtue that results from finding balance in the conflict. The first 5
stages refer to infancy and childhood and the last 3 stages to adulthood: