The nurse is providing care for a comatose patient and regularly assessing for potential complications. What complications should the nurse be looking for?
Venous thromboembolism
Hemorrhage
Contractures
Pressure ulcers
Pneumonia
Correct Answer : A,C,D,E
Choice A rationale
Venous thromboembolism (VTE) is a serious complication that can occur in comatose patients. Immobility is a major risk factor for VTE, and comatose patients are often immobile. Therefore, nurses should be vigilant for signs of VTE, such as swelling, pain, or redness in the extremities.
Choice B rationale
Hemorrhage is not typically a direct complication of coma. However, the underlying cause of the coma, such as a traumatic brain injury, could potentially lead to hemorrhage.
Choice C rationale
Contractures, or the shortening and hardening of muscles, tendons, or other tissue, can occur in comatose patients due to prolonged immobility. Regular movement and physiotherapy can help prevent this complication.
Choice D rationale
Pressure ulcers, also known as bedsores, are a common complication in comatose patients. They occur when there is prolonged pressure on the skin, usually over bony areas. Regular turning and good skin care can help prevent pressure ulcers.
Choice E rationale
Pneumonia is a common complication in comatose patients, often resulting from aspiration (inhaling food, stomach acid, or saliva into the lungs)2. Nurses should be vigilant for signs of pneumonia, such as fever, cough, and difficulty breathing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["35 "]
Explanation
Step 1 is to calculate the total daily dosage in milligrams. This is done by multiplying the weight of the client by the ordered daily dosage. So, 70 kg × 25 mg/kg = 1750 mg/day.
Step 2 is to divide the total daily dosage by the number of doses per day to get the dosage per dose. So, 1750 mg ÷ 2 = 875 mg/dose.
Step 3 is to calculate the volume of the dose in milliliters. The supply of Amoxicillin is 125 mg/5 mL, which means there are 125 mg of Amoxicillin in every 5 mL. So, to find out how many milliliters contain 875 mg, we set up a proportion: (125 mg / 5 mL) = (875 mg / x mL). Solving for x gives x = (875 mg × 5 mL) ÷ 125 mg = 35 mL. Therefore, the correct dosage for one dose is 35 mL.
Correct Answer is A
Explanation
Choice A rationale
The patient lying in bed with their head elevated to 35 degrees while eating could pose a risk for aspiration, especially for a patient with Huntington’s disease. Huntington’s disease is a neurodegenerative disorder that can cause difficulties with swallowing and motor control.
Therefore, it is recommended that the patient be as upright as possible, ideally in a seated position, during meals to reduce the risk of aspiration.
Choice B rationale
Providing thickened liquids is a common intervention for patients with Huntington’s disease who have difficulty swallowing. Thickened liquids are easier to control and swallow, reducing the risk of aspiration.
Choice C rationale
Not rushing the patient in eating each bite is a recommended practice. Patients with Huntington’s disease often have difficulty with motor control, including swallowing. Allowing the patient to take their time can help prevent choking and aspiration.
Choice D rationale
Ensuring that the patient’s food is minced is another recommended practice for patients with Huntington’s disease. Minced food is easier to chew and swallow, which can help prevent choking and aspiration.
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