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A client with a long history of smoking is being assessed by a nurse. Which finding is a common complication of chronic obstructive pulmonary disease (COPD)?
- A. Decreased anteroposterior chest diameter
- B. Increased breath sounds
- C. Prolonged expiratory phase
- D. Increased chest expansion
Correct Answer: C
Rationale: Step-by-step rationale:
1. COPD is characterized by airway obstruction, leading to difficulty exhaling.
2. Prolonged expiratory phase is a common finding due to air trapping.
3. This leads to hyperinflation and increased residual volume.
4. Decreased anteroposterior chest diameter is not typical in COPD.
5. Increased breath sounds and chest expansion are not common in COPD.
In summary, choice C is correct because it directly relates to the pathophysiology of COPD, while the other choices are not consistent with the condition.
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Which action best demonstrates respect for autonomy when working with a client?
- A. Asks if the client has questions before signing a consent form
- B. Provides the client with accurate information when questioned
- C. Honors the promises made to the client and family
- D. Ensures fair treatment of the client compared to others
Correct Answer: A
Rationale: The correct answer is A because asking if the client has questions before signing a consent form shows respect for autonomy by allowing the client to make an informed decision. This action promotes the client's right to self-determination and involvement in the decision-making process. Choice B focuses on providing information when questioned but may not actively involve the client in the decision-making process. Choice C refers to honoring promises and not necessarily respecting autonomy. Choice D relates to fairness but does not directly address autonomy or the client's decision-making ability.
During a home visit to an older client living alone post-coronary artery bypass graft, what finding prompts the nurse to consider additional referrals?
- A. Dirty carpets requiring vacuuming
- B. Expired food found in the refrigerator
- C. Outdated medications stored in the kitchen
- D. Presence of multiple cats in the home
Correct Answer: B
Rationale: The correct answer is B (Expired food found in the refrigerator) because it poses a potential health risk to the client. Expired food can lead to foodborne illnesses, especially for an older adult post-surgery. Dirty carpets (choice A) may not directly impact the client's health. Outdated medications (choice C) can be addressed by the nurse without additional referrals. The presence of multiple cats (choice D) may be a concern for allergies or cleanliness, but it is not as urgent as expired food in terms of health risks.
A client calls to report redness to the sclera, itching of the eyes, and increased lacrimation for several hours. What should you direct the caller to do first?
- A. Please call your doctor.'
- B. Apply a cool compress to your eyes.'
- C. If you are wearing contact lenses, remove them.'
- D. Take an over-the-counter antihistamine.'
Correct Answer: C
Rationale: Removing contact lenses is the first step to prevent further irritation and allow proper assessment of the eye condition.
Which of the following are the treatments of a non-severe sty?
- A. Cold compresses
- B. Warm soaks
- C. Limited sensory stimulation
- D. Incision and drainage
Correct Answer: B
Rationale: Warm soaks help reduce inflammation and promote healing of a non-severe sty.
Which factors place a client at risk for serotonin syndrome?
- A. Coprescription of antidepressants from different classes such as MAOIs and SSRIs
- B. Abnormal levels of cortisol in the body
- C. Adequate time between weaning from one antidepressant drug to initiating another
- D. Premenstrual syndrome
Correct Answer: A
Rationale: Combining certain classes of antidepressants increases serotonin levels excessively, leading to serotonin syndrome.