A nurse is obtaining a preoperative medical and surgical history from a client scheduled for a cataract extraction procedure. Which of the following client statements require further investigation by the nurse?
"l stopped taking aspirin last week."
"l did not put my contact lenses in this morning."
"l took my blood pressure meds with a sip of water."
"l had a cough and runny nose a couple days ago."
The Correct Answer is D
A. "I stopped taking aspirin last week.": Stopping aspirin medication prior to surgery is often advised to reduce the risk of bleeding during and after the procedure. The nurse may confirm the timing of discontinuation with the client and verify if any other anticoagulant medications are being taken.
B. "I did not put my contact lenses in this morning.": Removing contact lenses before surgery is a routine precaution to prevent potential corneal abrasions or complications during the procedure. This statement indicates the client is following preoperative instructions.
C. "I took my blood pressure meds with a sip of water.": Taking blood pressure medications with a small amount of water is generally acceptable before surgery. However, the nurse may verify the specific medications the client is taking and their dosing schedule to ensure compliance.
D. "I had a cough and runny nose a couple days ago.": This statement requires further investigation as respiratory symptoms, such as cough and runny nose, may indicate an underlying respiratory infection. Infections can increase the risk of complications during surgery, such as anesthesia-related respiratory issues or postoperative infections. The nurse should assess the severity and duration of the symptoms, inquire about any fever or recent exposure to illnesses, and consider notifying the surgical team for further evaluation and decision-making regarding the client's surgical readiness.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C"]
Explanation
A. Limit exercise to 10 min, 2 days per week. This recommendation is incorrect. Regular physical activity is essential for heart health. The American Heart Association recommends at least 150 minutes of moderate-intensity aerobic exercise or 75 minutes of vigorous-intensity aerobic exercise per week, spread throughout the week.
B. Monitor blood pressure This recommendation is correct. Monitoring blood pressure is an essential aspect of heart disease prevention. High blood pressure (hypertension) is a significant risk factor for heart disease, so regular monitoring allows for early detection and management.
C. Lose weight if necessary. This recommendation is correct. Maintaining a healthy weight or losing weight if overweight or obese is important for heart disease prevention. Excess weight, especially around the abdomen, increases the risk of heart disease and other health conditions.
D. Eat a diet high in saturated fats. This recommendation is incorrect. A diet high in saturated fats is associated with an increased risk of heart disease. Instead, the nurse should encourage a heart-healthy diet that includes fruits, vegetables, whole grains, lean proteins, and healthy fats.
E. Maintain current cholesterol level This recommendation is not entirely accurate. While maintaining healthy cholesterol levels is important for heart health, individuals with high cholesterol levels may need to take steps to lower their cholesterol through lifestyle modifications and, in some cases, medication. Therefore, simply maintaining current cholesterol levels may not be sufficient for heart disease prevention.
Correct Answer is ["A","C","E"]
Explanation
A. Confusion: Individuals with Alzheimer's disease often experience confusion due to memory loss, disorientation, and difficulty processing information. Confusion can contribute to wandering behavior as the individual may become lost or disoriented in familiar surroundings, leading them to wander in search of familiar people or places.
C. Agitation: Agitation, characterized by restlessness, pacing, or irritability, is commonly observed in individuals with Alzheimer's disease. Agitation can be triggered by various factors such as environmental stimuli, changes in routine, or unmet needs. It can escalate and prompt wandering behavior as the individual seeks to alleviate discomfort or agitation.
E. Distraction: Individuals with Alzheimer's disease may easily become distracted by environmental stimuli or sensory cues, which can lead to wandering behavior. Distraction can impair the individual's ability to maintain attention to their surroundings, increasing the likelihood of wandering episodes.
The following options are not directly associated with wandering behavior in individuals with Alzheimer's disease:
B. Distress: While distress may be experienced by individuals with Alzheimer's disease due to various factors such as confusion, agitation, or environmental changes, it is not a specific manifestation that puts the client at risk for wandering. Distress may exacerbate wandering behavior in some cases but is not a primary risk factor.
D. Depression: Depression is a common comorbidity in individuals with Alzheimer's disease and can contribute to overall behavioral changes and functional decline. However, depression alone is not a direct manifestation that puts the client at risk for wandering. Wandering behavior is more closely associated with cognitive impairment, agitation, and environmental factors rather than depression.
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