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 female client complains to the nurse at the health department that she has fatigue, shortness of breath, and lightheadedness. Her history reveals no significant medical problems. She states that she is always on a fad diet without any vitamin supplements. Which tests should the nurse expect the client to have first?
- A. peptic ulcer studies
- B. complete blood count, including hematocrit and hemoglobin
- C. genetic testing
- D. hemoglobin electrophoresis
Correct Answer: B
Rationale: The initial tests to determine the basis for her symptoms (considering her fad dieting) should be a complete blood count, urinalysis, blood sugar, and other tests. The decision about further testing is then made based on these results, her history, and other factors.
Which of the following statements is correct regarding rape?
- A. Most rapes are reported
- B. Legally, a woman can be raped by her spouse
- C. Prosecution and conviction for rape is easy
- D. The most common location of rape is the victim's own home
Correct Answer: B
Rationale: Spousal rape is legally recognized as non-consensual sexual intercourse within marriage. Most rapes are underreported, prosecution is challenging, and rapes occur in various locations, not predominantly at home.
Appropriate care for a client with neutropenia includes:
- A. plenty of fresh fruits and vegetables.
- B. a semi-private room.
- C. wearing a mask when out of the room.
- D. routine hand washing.
Correct Answer: C
Rationale: When a client is neutropenic, they lack the ability to fight off infection. The mask is to prevent exposure to any upper-respiratory infections.
Herbal therapy has several indications for use. Primarily, herbal therapy is:
- A. used to treat many common complaints and diseases.
- B. used to promote certain types of low-carb diets.
- C. used as an adjunct to medications.
- D. used to create a diet without salt and carbohydrates.
Correct Answer: A
Rationale: Herbal therapy is used to treat many common complaints and diseases.
A nurse is reviewing a patient's medical record. The record indicates the patient has limited shoulder flexion on the left. Which plane of movement is limited?
- A. Horizontal
- B. Sagittal
- C. Frontal
- D. Vertical
Correct Answer: B
Rationale: Sagittal motion occurs in the midline plane of the body.