Msncb Medical-surgical Nursing Exam Prep

Hypertension refers to high blood pressure, which is not expected in a patient who is haemorrhaging from different trauma sites and experiencing hypovolemia (low blood volume). Counteractive mechanisms related to hypovolemia, such as the activation of the sympathetic nervous system, would typically cause symptoms such as oliguria (decreased urine output), tachycardia (rapid heart rate), and tachypnea (rapid breathing) in order to compensate for the decreased blood volume. Therefore, hypertension would not be expected in this scenario.

The nurse should assess Mr. Kim for the development of dumping syndrome by determining the presence of diarrhea. Dumping syndrome is a condition that occurs after a Billroth I procedure, where food moves too quickly from the stomach to the small intestine. This can lead to symptoms such as abdominal pain, nausea, vomiting, and diarrhea. Therefore, assessing for the presence of diarrhea is important in identifying if Mr. Kim is experiencing dumping syndrome.

The nurse would monitor for respiratory obstruction as a complication of thyroidectomy. This is because during the surgery, there is a risk of damage to the laryngeal nerves or trachea, which can lead to difficulty in breathing or complete airway obstruction. It is crucial for the nurse to closely monitor the patient's respiratory status post-surgery to ensure early detection and prompt intervention if any signs of respiratory obstruction occur.

Mr. Sam, a 52-year-old African-American who smokes cigarettes, is at the greatest risk for developing hypertension. African-Americans have a higher prevalence of hypertension compared to other racial groups. Smoking is also a risk factor for hypertension as it can cause damage to the blood vessels and increase blood pressure. Therefore, the combination of being African-American and a smoker puts Mr. Sam at the highest risk for developing hypertension.

The nurse should continue the current plan of care because it is normal for there to be no measurable fecal emptying from the colostomy immediately after surgery. It takes time for the digestive system to start functioning again after a colostomy. The nurse should monitor the patient closely and assess for any signs of complications, but there is no need to panic or call the doctor immediately. Encouraging the patient to increase fluid intake is a good idea to prevent dehydration, but it will not necessarily stimulate fecal emptying at this stage.

Performing active-assistive leg exercises helps to promote blood circulation and prevent the formation of blood clots (thrombus). These exercises help to keep the blood flowing and prevent stagnation in the legs, reducing the risk of thrombus occurrence. Elastic stockings also aid in preventing blood pooling and promote circulation. Encouraging adequate fluids helps to prevent dehydration, which can increase the risk of blood clot formation. Gently massaging the legs with lotion may provide temporary relief but does not directly prevent thrombus occurrence. Therefore, performing active-assistive leg exercises is the most effective intervention to prevent thrombus occurrence in post-operative clients.

The nurse should palpate the back of the neck and shoulders for evidence of bleeding after a thyroidectomy because bleeding in this area can be a sign of hemorrhage. Palpating allows the nurse to feel for any swelling, tenderness, or abnormal sensations that may indicate bleeding. This method is more direct and reliable than simply inspecting the dressing, as bleeding may not always be visible on the surface. Checking the latest hemoglobin can provide additional information, but it may not be the initial assessment strategy for detecting bleeding.

After a gastrectomy, the stomach is either partially or completely removed, which can lead to a decrease in the production of intrinsic factor. Intrinsic factor is necessary for the absorption of vitamin B12 in the small intestine. Without sufficient intrinsic factor, the body is unable to absorb vitamin B12 properly, leading to a condition known as pernicious anemia. Therefore, the nurse must observe for signs of pernicious anemia after gastrectomy to ensure early detection and appropriate treatment.

After a thyroid scan with radioactive iodine for a thyroid nodule, no special radiation precautions need to be taken. This is because the amount of radioactive iodine used in the scan is minimal and does not pose a significant radiation risk to others. Therefore, there is no need to segregate the client in a private room or implement any specific radiation precautions.

A diminished secretion of aldosterone would result in hyperkalemia. Aldosterone plays a key role in regulating potassium levels in the body. It acts on the distal tubules of the kidneys to increase the reabsorption of sodium and the excretion of potassium. Therefore, when aldosterone secretion is reduced, there is a decreased excretion of potassium, leading to an accumulation of potassium in the blood, which causes hyperkalemia.