Nokea
A client is admitted with suspected pneumothorax. Which finding is most significant in confirming the diagnosis?
- A. Deviation of the trachea to the unaffected side
- B. Muffled heart sounds on the affected side
- C. Increased breath sounds on the affected side
- D. Decreased chest movement on the affected side
Correct Answer: A
Rationale: Tracheal deviation to the unaffected side is a hallmark of tension pneumothorax, indicating mediastinal shift due to air trapping, confirming the diagnosis.
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The nurse is teaching the client with AIDS regarding needed changes in food preparation. Which statement indicates that the client understands the nurse's teaching?
- A. Adding fresh ground pepper to my food will improve the flavor.
- B. Meat should be thoroughly cooked to the proper temperature.
- C. Eating cheese and yogurt will prevent AIDS-related diarrhea.
- D. It is important to eat four to five servings of fresh fruits and vegetables a day.
Correct Answer: B
Rationale: Thoroughly cooking meat reduces the risk of foodborne infections, which is critical for clients with AIDS due to their compromised immune systems.
A psychiatric client has been stabilized and is to be discharged. The nurse will recognize client insight and behavioral change by which of the following client statements?
- A. When I get home, I will need to take my medicines and call my therapist if I have any side effects or begin to hear voices.'
- B. If I have any side effects from my medicines, I will take an extra dose of Cogentin.'
- C. When I get home, I should be able to taper myself off the Haldol because the voices are gone now.'
- D. As soon as I leave here, I'm throwing away my medicines. I never thought I needed them anyway.'
Correct Answer: A
Rationale: The client verbalizes that he is responsible for compliance and keeping the treatment team member informed of progress. This behavior puts him at the lowest risk for relapse. Noncompliance is a major cause of relapse. This statement reflects lack of responsibility for his own health maintenance. This statement reflects lack of insight into the importance of compliance. This statement reflects no insight into his illness or his responsibility in health maintenance.
Clinical manifestations seen in left-sided rather than in right-sided heart failure are:
- A. Elevated central venous pressure and peripheral edema
- B. Dyspnea and jaundice
- C. Hypotension and Hepatomegaly
- D. Decreased peripheral perfusion and rales
Correct Answer: D
Rationale: Hypothermia and azotemia are signs, but not cardinal signs, of diabetes insipidus. (A, B, C) Clinical manifestations of right-sided heart failure are weakness, peripheral edema, jugular venous distention, hepatomegaly, jaundice, and elevated central venous pressure. Clinical manifestations of left-sided heart failure are left ventricular dysfunction, decreased cardiac output, hypotension, and the backward failure as a result of increased left atrium and pulmonary artery pressures, pulmonary edema, and rales.
During an examination, the nurse notes that an infant has diaper rash on the convex surfaces of his buttocks, inner thighs, and scrotum. Which of the following nursing interventions will be most effective in resolving the condition?
- A. Coating the inflamed areas with zinc oxide
- B. Using talcum powder on the inflamed areas to promote drying
- C. Removing the diaper entirely for extended periods of time
- D. Cleaning the inflamed area thoroughly with disposable wet 'wipes' at each diaper change
Correct Answer: C
Rationale: Removing the diaper and exposing the area to air and light facilitate drying and healing, effectively resolving diaper rash.
A client with a right lobectomy is being transported from the intensive care unit to a medical unit. The nurse understands that the client's chest drainage system:
- A. Can be disconnected from suction if the chest tube is clamped
- B. Can be disconnected from suction, but the chest tube should remain unclamped
- C. Must remain connected by means of a portable suction
- D. Must be kept even with the client's shoulders during the transport
Correct Answer: B
Rationale: The chest drainage system can be disconnected from suction during transport, but the tube must remain unclamped to allow air or fluid to escape, preventing pneumothorax. Portable suction is not always needed.