A 60-year-old man was admitted for cholecystitis that resulted in a cholecystectomy. On his third day of hospitalization, he begins to sweat profusely, tremble, and has a blood pressure of 160/100. Based on these findings, what focused assessment should the nurse complete?
Withdrawal problems
Circulatory problems
Cardiac problems
Respiratory problems
The Correct Answer is A
A. Withdrawal problems: These symptoms are consistent with alcohol or drug withdrawal, which can occur in hospitalized patients with a history of substance use.
B. Circulatory problems: While hypertension is a circulatory issue, the sweating and trembling suggest withdrawal rather than primary circulatory problems.
C. Cardiac problems: While important to rule out, the combination of symptoms points more towards withdrawal.
D. Respiratory problems: The primary symptoms here are not indicative of respiratory issues.
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Related Questions
Correct Answer is B
Explanation
A. Transport victim to hospital: While transport to the hospital is necessary, it is not the immediate priority when the victim is still on fire.
B. Stop, drop, and roll: The first action for someone whose clothing is on fire is to stop, drop, and roll to extinguish the flames and prevent further burns.
C. Cover victim with clean cloth or sheet: Covering with a clean cloth is important after the flames have been extinguished but not the first step when the victim is still burning.
D. Remove all nonadherent clothing and jewelry: Removing clothing and jewelry should be done after the flames are extinguished and initial care has been administered.
Correct Answer is D
Explanation
A. Dermis. The dermis contains connective tissue, blood vessels, and other structures but not melanocytes.
B. Superficial fascia. The superficial fascia, or hypodermis, is primarily composed of fat and connective tissue and does not contain melanocytes.
C. Epidermis. Melanocytes are located in the basal layer of the epidermis, where they produce melanin.
D. Loose connective tissue. Loose connective tissue is found in various parts of the body but does not contain melanocytes responsible for skin pigmentation.
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