Medical Follow-up Scenarios

Front

Key nursing interventions for Tina’s pressure ulcer include: Regular repositioning to alleviate pressure, Applying moisturizing creams, Ensuring adequate nutrition, All of the above

Back

All of the above

Front

Which action is most important for Daniel to prevent complications related to immobility following a stroke? Options: Encourage rest between turns, Perform passive range of motion (ROM) exercises, Reduce fluid intake to prevent incontinence, Turn every 6 hours

Back

Perform passive range of motion (ROM) exercises

Front

Maria, a 60-year-old woman with a history of stroke, is receiving IV fluids in the hospital. She is accidentally given hypotonic fluids, and over the next several hours, she begins to feel confused and has a headache. What is the likely cause of Maria’s symptoms?

Back

Cerebral edema from fluid shift

Answer explanation

• What is concentration?
  Concentration is like how much "stuff" (like salt or sugar) is in a liquid. When we talk about concentration in fluids, we mean how much salt or sugar is in the liquid compared to the amount of liquid itself.

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  Higher concentration (like in salty water)

  Imagine you have a glass of water and you add a lot of salt to it. Now, the water is very salty—this means the water has a higher concentration of salt. There’s more salt compared to the amount of water.

  Lower concentration (like in plain water)

  Now imagine you have a glass of water with just a tiny bit of salt. The water is almost not salty at all, which means the water has a lower concentration of salt. There’s a lot more water than salt.

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  How this works in your body

  When we put fluids into our body, the body likes to balance things out. If the fluid you get has more stuff (like salt or sugar) than your cells, the water in your cells will move out of the cells to balance things.

  But if the fluid has less stuff (like salt or sugar), the water will move into the cells to balance things out.

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  So, if a patient like Maria gets a fluid with less stuff than her cells, water moves into her cells (making them swell), and this can cause problems like headaches and confusion.

• Hypotonic fluids have a lower concentration of solutes (such as sodium) compared to the blood. When hypotonic fluids are administered, the body’s cells, which have a higher concentration of solutes than the fluid, will draw water into the cells to balance the concentration. This causes cells to swell. In brain cells, this swelling can lead to cerebral edema, which causes symptoms like headache, confusion, and in severe cases, seizures or coma.

• Hypertonic fluids have a higher concentration of solutes compared to the blood, leading water to shift out of the cells to balance the solute concentration. This can result in cell shrinkage and dehydration, potentially causing issues like hypovolemia or dehydration-related complications.

Front

Mrs. Adams, a 65-year-old female with PMH of HTN and HLD presents to the emergency department with a sudden onset of headache, mild confusion, and unsteadiness. She states she 'just doesn’t feel right.' What is the priority nursing intervention?

Back

Initiate a rapid neurological response

Front

An older adult reports trouble reading, recognizing faces, and complains that "the center of everything looks blurry, but I can still see the edges." What is the most appropriate nursing intervention? Options: Encourage warm compresses to relieve irritation, Recommend magnifiers or large-print reading material, Instruct the client to avoid all light exposure, Teach the client to use eye drops hourly.

Back

Recommend magnifiers or large-print reading material

Answer explanation

Symptoms suggest macular degeneration. Central vision loss calls for tools that aid with fine detail.

Because macular degeneration can’t be reversed, the goal is to help the person adapt. Tools like magnifiers and large-print materials make it easier to read and function with reduced central vision. It’s the most helpful and practical nursing intervention.

Front

A client who has worn hearing aids for 2 years reports increasing difficulty hearing, especially in noisy settings. The nurse notes the hearing aid appears functional. What is the next best step?

Back

Refer to audiology for reassessment

Answer explanation

Progressive sensorineural hearing loss may require updated devices or further evaluation.

Front

True or False: A client reports sudden onset of seeing floaters, light flashes, and a curtain over their field of vision. The nurse should delay notifying the provider until vision changes are confirmed by an eye exam.

Back

FALSE

Answer explanation

This is a potential retinal detachment and a medical emergency.

Front

A nurse is reviewing lab results for a client who reports fatigue and shortness of breath with activity. The client's hemoglobin is 8.2 g/dL and hematocrit is 27%. What should the nurse do next?

Back

Notify the provider and assess for signs of bleeding or nutritional deficiencies.

Answer explanation

Normal hemoglobin: ~12–16 g/dL (female), 14–18 g/dL (male); hematocrit: ~36–48%. These values are low and suggest anemia, requiring evaluation.

Front

A 45-year-old female client presents with symptoms of fatigue, weight gain, cold intolerance, and constipation. Her lab results show:

• T3: 1.2 ng/mL (Normal range: 1.0–2.0 ng/mL)
• TSH: 6.2 µIU/mL (Normal range: 0.4–4.0 µIU/mL)

Which of the following should be a priority nursing intervention for this client? Options: A. Educate the client to take thyroid medication on an empty stomach in the morning, Educate the client to take thyroid medication at night, Monitor for myxedema symptoms, Encourage the client to increase fiber intake to prevent constipation

Back

Educate the client to take thyroid medication on an empty stomach in the morning.

Answer explanation

The patient’s elevated TSH and symptoms suggest hypothyroidism. The nurse should prioritize educating the client to take thyroid medication on an empty stomach in the morning for optimal absorption

Front

A patient with chronic kidney disease has a persistently low hemoglobin level despite adequate iron intake. Which underlying cause best explains this finding?

Back

Reduced erythropoietin secretion

Answer explanation

The kidneys make erythropoietin, which tells the body to make red blood cells. In chronic kidney disease, less is made — so even with enough iron, the body can’t make enough RBCs.

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Why not the others?

• A affects white cells, not RBCs. The kidneys have nothing to do with WBCs

• B is about platelets, not hemoglobin. Again, kidneys dont affect platelets

• C points to a spleen issue, not kidneys.