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 A
Explanation
Choice A rationale
Myasthenia gravis is a neuromuscular disorder characterized by weakness and fatigue of voluntary muscles. Edrophonium is a medication that is used in the diagnosis and treatment of myasthenia gravis. It works by inhibiting the breakdown of acetylcholine, a neurotransmitter that transmits signals in the nervous system, thereby improving muscle strength.
Choice B rationale
Myasthenia gravis is not a disorder of motor and sensory dysfunction. It primarily affects the neuromuscular junction, leading to muscle weakness and fatigue. Sensory function is typically not affected in myasthenia gravis.
Choice C rationale
This statement is correct in that myasthenia gravis does not cause sensory impairment. However, it does not indicate an understanding of the disease as a whole, as it does not address the primary symptom of muscle weakness.
Choice D rationale
Myasthenia gravis does cause progressive muscle weakness, but it does not cause sensory deficits. Therefore, this statement indicates a partial understanding of the disease.
Correct Answer is B
Explanation
Choice A rationale
Analgesics can be used to manage pain associated with Bell’s palsy. Therefore, this statement does not indicate a need for further education.
Choice B rationale
This is the correct answer. Chewing on the affected side can actually exacerbate swallowing issues. Therefore, this statement indicates a need for further education.
Choice C rationale
Brushing teeth should not be affected by Bell’s palsy. Therefore, this statement does not indicate a need for further education.
Choice D rationale
Applying a protective eye shield before going to bed is a recommended practice for patients with Bell’s palsy. This helps to protect the eye from injury and keep it moist, as Bell’s palsy can cause difficulty in blinking or closing the eye.
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