A nurse cares for a client who had a partial laryngectomy 10 days ago. The client states that all food tastes bland. How would the nurse respond?
- A. I will consult the speech therapist to ensure you are swallowing properly.
- B. This is normal after surgery. What types of food do you like to eat?
- C. I will ask the dietitian to change the consistency of the food in your diet.
- D. Replacement of protein, calories, and water is very important after surgery.
Correct Answer: B
Rationale: Step 1: Acknowledge client's concern about bland taste.
Step 2: Validate normalcy post-laryngectomy.
Step 3: Assess client's food preferences for individualized care.
Step 4: Encourage open communication for effective care plan.
Step 5: Addressing the issue holistically promotes client-centered care.
Summary:
- A: Focuses on swallowing, not taste.
- C: Addresses food consistency, not taste.
- D: Important but not directly related to client's concern.
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The organs of the respiratory zone of the respiratory system include all the following EXCEPT:
- A. trachea
- B. small bronchioles
- C. alveoli ducts
- D. alveoli
Correct Answer: A
Rationale: The correct answer is A: trachea. The trachea is not part of the respiratory zone, which is where gas exchange occurs. The respiratory zone includes the small bronchioles, alveoli ducts, and alveoli. The trachea is part of the conducting zone, which is responsible for transporting air to and from the respiratory zone. Therefore, the trachea is not directly involved in gas exchange, making it the correct answer. The other choices, B: small bronchioles, C: alveoli ducts, and D: alveoli, are all part of the respiratory zone and play a crucial role in gas exchange.
The nurse on the intermediate care unit received a change-of-shift report on four patients with hypertension. Which patient should the nurse assess first?
- A. 48-yr-old with a blood pressure of 160/92 mm Hg who reports chest pain
- B. 52-yr-old with a blood pressure of 198/90 mm Hg who has leg cramping
- C. 50-yr-old with a blood pressure of 190/104 mm Hg who has a creatinine of 1.1 mg/dL
- D. 43-yr-old with a blood pressure of 172/98 mm Hg whose urine shows microalbuminuria.
Correct Answer: A
Rationale: The correct answer is A. The nurse should assess the 48-yr-old with a blood pressure of 160/92 mm Hg who reports chest pain first because chest pain can be a sign of a cardiac issue, which could be life-threatening. Assessing this patient first is crucial to rule out any acute cardiac events. Leg cramping (choice B) is a common symptom in hypertensive patients but is not as urgent as chest pain. High creatinine levels (choice C) may indicate kidney issues but do not require immediate assessment compared to chest pain. Microalbuminuria (choice D) is a sign of kidney damage in hypertension but does not pose an immediate threat like chest pain.
Which of the following is NOT found in lung tissue?
- A. blood capillaries
- B. alveolar sacs
- C. interstitial fluid
- D. muscle
Correct Answer: D
Rationale: The correct answer is D: muscle. Lung tissue does not contain muscle tissue; instead, it is primarily composed of alveolar sacs for gas exchange, blood capillaries for oxygen exchange, and interstitial fluid for support. Muscles are not part of the structure of the lungs as they are not involved in the respiratory process. In summary, muscles are not found in lung tissue, making option D the correct choice.
O2 dissociation curve shift to R) by all of the following except
- A. Increase [H+]
- B. pCO2
- C. Increase temperature
- D. Carbon monoxide
Correct Answer: D
Rationale: The correct answer is D: Carbon monoxide. Carbon monoxide does not shift the O2 dissociation curve to the right (R) because it binds to hemoglobin with a higher affinity than oxygen, causing a leftward shift (L). Increased [H+], pCO2, and temperature all shift the curve to the right by decreasing hemoglobin's affinity for oxygen.
The nurse assesses wheezes in a patient with asthma and realizes that these breath sounds result from:
- A. Increased thickness of respiratory secretions.
- B. Use of accessory muscles of respiration.
- C. Tachypnea and tachycardia.
- D. Movement of air through narrowed airways.
Correct Answer: D
Rationale: The correct answer is D because wheezes in asthma are caused by the movement of air through narrowed airways due to bronchoconstriction and inflammation. This narrowing leads to turbulent airflow, resulting in the characteristic high-pitched musical sound of wheezes. Increased thickness of respiratory secretions (A) may cause crackles, not wheezes. Use of accessory muscles (B) indicates respiratory distress but does not directly cause wheezes. Tachypnea and tachycardia (C) are common in asthma but do not directly cause wheezes. Thus, D is the most directly related to the pathophysiology of wheezes in asthma.