Nokea
A client with asthma has developed viral pharyngitis. Which of the following findings should the nurse expect?
- A. Petechiae on the chest and abdomen
- B. WBC 16,000/mm3
- C. Negative throat culture
- D. Severe hyperemia of pharyngeal mucosa
Correct Answer: C
Rationale: The correct answer is C, negative throat culture. In viral pharyngitis, the infection is caused by a virus, not bacteria. Therefore, a throat culture would be negative as it tests for bacterial infection. Option A is incorrect as petechiae are more commonly seen in conditions like meningococcal sepsis. Option B is incorrect as a WBC count of 16,000/mm3 is more indicative of a bacterial infection. Option D is incorrect as severe hyperemia of the pharyngeal mucosa is more typical of bacterial pharyngitis, not viral.
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What action should the nurse include in teaching Mr. Ross about skin care of the irradiated area?
- A. Applying ointment or lotion to the skin
- B. Washing the area with soap and water
- C. Keeping the area dry and open to air
- D. Massaging the area and exposing it to sunlight
Correct Answer: C
Rationale: Protecting the skin from irritation and moisture promotes healing.
A healthcare professional is reviewing the arterial blood gas results for a client in the ICU who has kidney failure and determines the client has respiratory acidosis. Which of the following findings should the healthcare professional expect?
- A. Widened QRS complexes
- B. Hyperactive deep tendon reflexes
- C. Bounding peripheral pulses
- D. Warm, flushed skin
Correct Answer: A
Rationale: The correct answer is A: Widened QRS complexes. Respiratory acidosis results from inadequate removal of carbon dioxide, leading to increased carbonic acid in the blood and a decrease in blood pH. This acidosis can cause electrolyte imbalances, including hyperkalemia, which can manifest as widened QRS complexes on an ECG due to the effect of high potassium levels on cardiac conduction. Hyperactive deep tendon reflexes (B) are associated with conditions such as hyperthyroidism or hypocalcemia. Bounding peripheral pulses (C) are seen in conditions like aortic regurgitation or hyperthyroidism. Warm, flushed skin (D) is more indicative of conditions like hyperthermia or sepsis.
While dining at a restaurant, a person begins to choke. Which of the following actions should the nurse take?
- A. Instruct the person to call 911.
- B. Ask the person if he/she can speak.
- C. Use the jaw-thrust maneuver.
- D. Perform abdominal thrusts.
Correct Answer: B
Rationale: The correct answer is B because asking the person if he/she can speak helps to determine if the airway is partially or completely obstructed. If the person can speak, it indicates that the airway is not completely blocked, and coughing may help dislodge the object. If the person cannot speak, it suggests a complete blockage, and immediate intervention is needed. In contrast, A is incorrect as the nurse should take action rather than instructing the person to call 911. C is incorrect because the jaw-thrust maneuver is used for assisting with breathing, not for choking. D is incorrect because abdominal thrusts are only performed when the person is unable to speak, indicating a complete airway obstruction.
What is most important to determine when completing Mr. Anderson’s nursing history?
- A. Known allergy to penicillin
- B. Work habits
- C. History of COPD
- D. Sleep and rest habits
Correct Answer: A
Rationale: Penicillin allergy is critical to know before administering antibiotics.
Which traits are clients with anorexia nervosa noted to have?
- A. Low self-esteem
- B. High self-esteem
- C. Perfectionism
- D. Intense desire to displease others
Correct Answer: C
Rationale: Perfectionism is a common trait among individuals with anorexia nervosa, driving their pursuit of unrealistic body ideals.