Nokea
A black client with asthma seeks emergency care for acute respiratory distress. Because of this client's dark skin, the nurse should assess for cyanosis by inspecting the:
- A. Lips
- B. Mucous membranes
- C. Nail beds
- D. Earlobes
Correct Answer: B
Rationale: The correct answer is B: Mucous membranes. Cyanosis, a bluish discoloration of the skin and mucous membranes, is an important sign of respiratory distress. In individuals with dark skin, cyanosis may be more easily detected in the mucous membranes, such as the lips and oral mucosa, compared to the skin. The lips (choice A), nail beds (choice C), and earlobes (choice D) may not always show cyanosis clearly in individuals with darker skin tones. Therefore, assessing the mucous membranes is the best option for identifying cyanosis accurately in this scenario.
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Tuberculosis in man is caused by
- A. A type of bacteria
- B. A virus
- C. A protozon
- D. Malnutrition
Correct Answer: A
Rationale: The correct answer is A: A type of bacteria. Tuberculosis is caused by Mycobacterium tuberculosis, a type of bacteria. This bacterium infects the lungs and can spread to other parts of the body. The other choices (B: A virus, C: A protozoan, D: Malnutrition) are incorrect because tuberculosis is specifically caused by a bacterial infection, not a virus, protozoan, or malnutrition. Bacteria can be identified through specific staining techniques and culture methods, distinguishing them from viruses and protozoa. Malnutrition is a risk factor for developing tuberculosis but is not the direct cause of the disease.
Which blood pressure (BP) finding by the nurse indicates that no changes in therapy are needed for a 78-yr-old patient with newly diagnosed hypertension?
- A. 98/56 mm Hg
- B. 118/76 mm Hg
- C. 128/92 mm Hg
- D. 142/78 mm Hg
Correct Answer: B
Rationale: The correct answer is B (118/76 mm Hg) because it falls within the recommended range for a 78-year-old patient with hypertension. The systolic BP should ideally be below 140 mm Hg and the diastolic BP below 90 mm Hg for this age group. Option A is too low for systolic BP, indicating hypotension. Option C has elevated diastolic BP, suggesting uncontrolled hypertension. Option D has high systolic BP, indicating a need for therapy adjustment. Thus, only option B aligns with the guidelines, making it the correct choice.
What instructions will you give the nursing assistant who will assist the client with ADLs? (Choose all that apply.)
- A. Use a lift sheet when moving and positioning the client in bed.
- B. Use an electric razor when shaving the client each day.
- C. Use a soft-bristled toothbrush or tooth sponge for oral care.
- D. Use a rectal thermometer to attain a more accurate body temperature.
Correct Answer: D
Rationale: The correct answer includes A, B, and C. Using a lift sheet (A), electric razor (B), and soft-bristled toothbrush (C) are safe practices during anticoagulation therapy. Using a rectal thermometer (D) is contraindicated due to bleeding risk.
Expiration involves
- A. Relaxation of diaphragm and intercostals muscles
- B. Contraction of diaphragm and intercostals muscles
- C. Contraction of diaphragm muscles
- D. Contraction of inter costal muscles
Correct Answer: A
Rationale: The correct answer is A because expiration involves the relaxation of the diaphragm and intercostal muscles. During expiration, the diaphragm moves up and the intercostal muscles relax, causing the thoracic cavity to decrease in volume. This increase in pressure forces air out of the lungs. Choice B is incorrect as it describes the process of inspiration, not expiration. Choice C is incorrect because expiration involves both the diaphragm and intercostal muscles, not just the diaphragm muscles. Choice D is incorrect as the intercostal muscles also relax during expiration, rather than contracting.
In an adult patient with bronchiectasis, what is a nursing assessment likely to reveal?
- A. Chest trauma
- B. Childhood asthma
- C. Smoking or oral tobacco use
- D. Recurrent lower respiratory tract infections
Correct Answer: D
Rationale: In an adult patient with bronchiectasis, a nursing assessment is likely to reveal recurrent lower respiratory tract infections due to the damaged and widened airways in the lungs.