Nokea
A client was involved in a motor vehicle accident in which the seat belt was not worn. The client is exhibiting crepitus, decreased breath sounds on the left, complains of shortness of breath, and has a respiratory rate of 34/min. Which of the following assessment findings should concern the nurse the most?
- A. temperature of 102°F and a productive cough
- B. arterial blood gases (ABGs) with a PaO2 of 92 and PaCO2 of 40 mmHg
- C. trachea deviating to the right
- D. barrel-chested appearance
Correct Answer: C
Rationale: A mediastinal shift is indicative of a tension pneumothorax along with the other symptoms in the question. Because the individual was involved in an MVA, assessment is targeted at acute traumatic injuries to the lungs, heart, or chest wall rather than other conditions indicated in the other choices.
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A nurse is instructing a patient on the order of sensations with the application of an ice water bath for a swollen right ankle. Which of the following is the correct order of sensations experienced with an ice water bath?
- A. cold, burning, aching, and numbness
- B. burning, aching, cold, and numbness
- C. aching, cold, burning and numbness
- D. cold, aching, burning and numbness
Correct Answer: A
Rationale: CBAN, cold, burn, ache, numbness
A 32-year-old female frequently comes to her primary care provider with vague complaints of headache, abdominal pain, and trouble sleeping. In the past, the physician has dutifully prescribed medication, but little else. Which of the following comments by the nurse to the physician is appropriate?
- A. Often women who are victims of domestic violence suffer vague symptoms such as abdominal pain.'
- B. Often women become offended if asked about their safety in relationships.'
- C. It is mandatory that all women be questioned about domestic violence.'
- D. How would you feel to know that her partner is beating her and you didn't ask?'
Correct Answer: A
Rationale: There is a correlation between vague symptoms, such as abdominal pain, and battered syndrome. The astute clinician should question any woman who presents with suspicious symptoms such as these. Rarely are women offended by a properly worded question, such as, 'Do you feel safe in your present relationship?' Studies show an increase in case finding when such questions are asked. It is not mandatory that all women are assessed for violence, but it is prudent that all persons new to a clinician be assessed by at least the one question noted previously. Castigating or shaming the physician typically does not improve client outcomes and might make for a difficult working environment for the nurse. Tactless comments, like the one in Choice 4, are not collegial and should be avoided.
Nursing considerations when caring for African-American clients include that:
- A. families are generally distant and unsupportive
- B. special hair, skin, and nail care might be required
- C. fad diets are a cultural norm
- D. clients are generally future-oriented
Correct Answer: B
Rationale: African-American clients may require specific hair, skin, and nail care due to unique characteristics like tightly coiled hair or higher risk of keloid scarring. The other options are stereotypes or incorrect: families are often supportive, fad diets are not a cultural norm, and future orientation is not a defining trait.
A female prostitute enters a clinic for treatment of a sexually transmitted disease. This disease is the most prevalent STD in the United States. The nurse can anticipate that the woman has which of the following?
- A. herpes
- B. chlamydia
- C. gonorrhea
- D. syphilis
Correct Answer: B
Rationale: Epidemiological studies indicate that chlamydia is the most prevalent sexually transmitted disease in the United States.
A nurse is assessing a patient's breath sounds. The patient has had a pneumonectomy to the right lung performed 48 hours ago. Which of the following conditions most likely exists?
- A. Decreased breath sound volume
- B. Elevated tidal volume
- C. Elevated respiratory capacity
- D. Wheezing
Correct Answer: A
Rationale: Breath sounds would be softer due to the removal of the right lung, reducing the area available for air exchange.