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.
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Related Questions
Correct Answer is D
Explanation
Choice D rationale
Teaching the patient to perform deep breathing and coughing exercises is a key intervention to address a potential complication after an ischemic stroke. These exercises can help prevent pneumonia, a common complication after stroke, by promoting lung expansion, improving oxygenation, and facilitating the clearance of secretions.
Choice A rationale
Keeping a urinary catheter in place for the entire duration of recovery is not typically recommended due to the increased risk of urinary tract infections. Catheters should be used sparingly and removed as soon as possible.
Choice B rationale
Providing three larger meals rather than frequent small meals does not specifically address a potential complication after an ischemic stroke. In fact, smaller, more frequent meals may be easier for some stroke patients to manage, particularly if they have difficulty swallowing.
Choice C rationale
Limiting the intake of insoluble fiber does not specifically address a potential complication after an ischemic stroke. A balanced diet with adequate fiber is generally recommended for stroke patients to promote bowel regularity and overall health.
Correct Answer is B
Explanation
Choice A rationale
Antiviral therapy is typically used to treat viral infections. However, meningitis is most commonly caused by bacteria. Therefore, antiviral therapy would not be the most effective treatment in this case.
Choice B rationale
Antibiotic therapy is the standard treatment for bacterial meningitis. The specific antibiotic or combination of antibiotics used depends on the type of bacteria causing the infection.
Therefore, after reviewing lab results that suggest meningitis, the nurse would anticipate the provider to prescribe antibiotic therapy.
Choice C rationale
Antiemetics are medications that help prevent and treat nausea and vomiting, which can be symptoms of meningitis, but they do not treat the underlying cause of meningitis.
Choice D rationale
Analgesics are used to relieve pain. While they might be used to manage the headache often associated with meningitis, they would not treat the infection itself.
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