Nokea
A client with chronic obstructive pulmonary disease (COPD) appears thin and disheveled. Which question should the nurse ask first?
- A. Do you have a strong support system?
- B. What do you understand about your disease?
- C. Do you experience shortness of breath with basic activities?
- D. What medications are you prescribed to take each day?
Correct Answer: C
Rationale: The correct question to ask first is C: "Do you experience shortness of breath with basic activities?" This is because shortness of breath is a common and concerning symptom in COPD patients that can greatly impact their quality of life and indicate disease progression. By addressing this symptom first, the nurse can assess the severity of the client's condition and determine the immediate need for intervention or treatment. Asking about support system (A) is important but not as urgent as addressing the primary symptom. Inquiring about the client's understanding of the disease (B) and medications (D) is also important but should come after addressing the immediate symptom of shortness of breath.
You may also like to solve these questions
What instruction should be included when teaching a client with asthma about using a metered-dose inhaler (MDI)?
- A. Shake the inhaler well before use.
- B. Inhale rapidly while administering the medication.
- C. Administer the medication while lying down.
- D. Hold the inhaler 2 inches away from the mouth while inhaling.
Correct Answer: A
Rationale: Rationale for Correct Answer A:
1. Shaking the inhaler well before use helps ensure proper mixing of the medication.
2. This action helps to distribute the medication evenly for effective delivery.
3. It prevents clogging and ensures the client receives the correct dose.
4. Shake-and-use approach is essential for optimal therapeutic benefits.
Summary of Incorrect Choices:
B: Inhaling rapidly may lead to improper medication delivery and increase the risk of side effects.
C: Administering medication while lying down may not allow the client to inhale the medication effectively.
D: Holding the inhaler too far away can result in decreased medication intake and reduced efficacy.
A cheerful, elderly widow comes to the community clinic for her annual check-up. She is in reasonably good health, but she has a hearing loss of 40 dB. She confides, 'I don't get out much. I used to be really active, but the older I get, the more trouble I have hearing. It can be really embarrassing.' What is the priority nursing diagnosis?
- A. Social Interaction, Impaired related to perceived inability to interact
- B. Disturbed Sensory Perception related to progressive hearing loss
- C. Knowledge Deficit related to pathophysiological processes
- D. Coping, Ineffective related to change in sensory abilities
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
What controls the cyclic changes between waking and sleep?
- A. Fluctuating levels of melatonin
- B. The environmental light-dark cycles
- C. Key nuclei in the brainstem, hypothalamus, and thalamus
- D. A variety of neuropeptides released from the nervous system
Correct Answer: C
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.
A healthcare professional is caring for four clients on intravenous heparin therapy. Which lab value possibly indicates a serious side effect has occurred?
- A. Hemoglobin: 14.2 g/dL
- B. Platelet count: 82,000/µL
- C. RBC count: 4.8 x 10^6/µL
- D. WBC count: 8.7 x 10^3/µL
Correct Answer: B
Rationale: The correct answer is B: Platelet count: 82,000/µL. A low platelet count (thrombocytopenia) is a serious side effect of heparin therapy, as it can lead to bleeding complications. Platelets are essential for normal blood clotting. Hemoglobin, RBC count, and WBC count are not directly affected by heparin therapy and do not indicate a serious side effect.