Nokea
A client with a new tracheostomy is being seen in the oncology clinic. What finding by the nurse best indicates that goals for the nursing diagnosis Impaired Self-Esteem are being met?
- A. The client demonstrates a good understanding of stoma care.
- B. The client has joined a book club that meets at the library.
- C. Family members take turns assisting with stoma care.
- D. Skin around the stoma is intact without signs of infection.
Correct Answer: B
Rationale: The correct answer is B because joining a book club indicates the client is engaging in social activities and pursuing interests, which can boost self-esteem. Choice A focuses on physical care, not self-esteem. Choice C involves family support, not necessarily self-esteem. Choice D only addresses physical health, not emotional well-being. Overall, engaging in social activities promotes self-worth and a sense of belonging, aligning with the goal of improving self-esteem.
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What condition could predispose a client to shock?
- A. The kidneys work improperly
- B. The heart fails as an effective pump
- C. Peripheral blood vessels massively constrict
- D. Blood volume increases
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
When assessing a client with pneumonia, which clinical manifestation should the nurse expect to find?
- A. Fremitus
- B. Hyperresonance
- C. Dullness on percussion
- D. Decreased tactile fremitus
Correct Answer: C
Rationale: The correct answer is C: Dullness on percussion. In pneumonia, the affected lung tissue becomes consolidated, leading to dullness on percussion due to decreased air movement. The rationale behind this is that consolidation causes the air-filled lung tissue to become filled with fluid and inflammatory cells, impairing normal sound transmission upon percussion.
Incorrect choices:
A: Fremitus - Increased tactile fremitus is typically found in pneumonia due to the denser lung tissue, making this choice incorrect.
B: Hyperresonance - Hyperresonance is commonly found in conditions like emphysema with increased lung air volume, not in pneumonia.
D: Decreased tactile fremitus - This is contradictory as pneumonia usually presents with increased tactile fremitus due to the consolidated lung tissue.
While caring for a client using O2 in the hospital, what assessment finding indicates that goals for a priority diagnosis are being met?
- A. 100% of meals being eaten by the client
- B. Intact skin behind the ears
- C. The client understanding the need for oxygen
- D. Unchanged weight for the past 3 days
Correct Answer: B
Rationale: The correct answer is B because intact skin behind the ears indicates proper oxygen delivery, ensuring the client's respiratory needs are being met. This assessment finding shows that the oxygen therapy is effective in improving oxygenation.
A: This choice is incorrect as the client's meal intake does not directly reflect the effectiveness of oxygen therapy.
C: Although important, the client's understanding of the need for oxygen does not directly indicate the success of the oxygen therapy.
D: Unchanged weight is not a direct indicator of the effectiveness of oxygen therapy in this situation.
Which of the following should be immediately reported to the physician?
- A. Change in color vision
- B. Crusty yellow drainage on eyelashes
- C. Increased lacrimation
- D. Curtain-like shadow across visual field
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Tim presents with an acute episode of gout. You expect the physician to prescribe
- A. Nonsteroidal anti-inflammatory medications and colchicine.
- B. Allopurinol and aspirin.
- C. Antibiotics and acetaminophen.
- D. Bisphosphonates and calcium.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.