The nurse is caring for a patient with elevated serum thyroid hormones and new-onset exophthalmos. The nurse establishes which nursing diagnosis?
1. Disturbed Body Image
2. Risk for Infection
3. Imbalanced Nutrition: More than Body Requirements
4. Fluid Volume Excess
1
Rationale 1: The bulging of the eyes characteristic of exophthalmos affects body image.
Rationale 2: The presence of exophthalmos may increase the risk of eye infection to some degree, but this diagnosis is not as likely to be a priority as another.
Rationale 3: A diagnosis of imbalanced nutrition is not related to exophthalmos.
Rationale 4: A diagnosis of excess fluid is not related to exophthalmos.
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A student asks the pharmacology instructor how succinylcholine differs from acetylcholine (ACh). What should the instructor respond?
A) "Succinylcholine is not broken down instantly." B) "It results in a prolonged contraction of the muscle." C) "The muscle becomes hyper stimulated by succinylcholine." D) Succinylcholine's duration of action is about 2 hours."
The nurse is caring for a patient who has undergone creation of a urinary diversion. Forty-eight hours postoperatively, the nurse's assessment reveals that the stoma is a dark purplish color. What is the nurse's most appropriate response?
A) Document the presence of a healthy stoma. B) Assess the patient for further signs and symptoms of infection. C) Inform the primary care provider that the vascular supply may be compromised. D) Liaise with the wound-ostomy-continence (WOC) nurse because the ostomy appliance around the stoma may be too loose.
The anatomy class is learning about the abdomen. The instructor would tell the class that the abdominal cavity is bordered on the back by
A) The lower rib cage B) The vertebral column C) The kidneys D) The midaxillary lines