Nokea
A female client is exhibiting signs of respiratory distress. Which of the following signs indicate a possible pneumothorax?
- A. Crackles or rales on the affected side
- B. Bradypnea and bradycardia
- C. Shortness of breath and sharp pain on the affected side
- D. Increased breath sounds on the affected side
Correct Answer: C
Rationale: With a pneumothorax, air occupies the pleural space. Crackles or rales are heard with increased fluid or secretions and would not be present with air in the space. With a pneumothorax, the client would experience tachypnea and tachycardia to compensate for the decrease in oxygenation. Symptoms of pneumothorax include shortness of breath, sharp pain on the affected side with movement or coughing, asymmetrical chest expansion, and diminished or absent breath sounds on the affected side. With a pneumothorax, breath sounds would be decreased on the affected side (indicates air in the pleural space).
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A group of nursing students at a local preschool day care center are going to screen each child's fine and gross motor, language, and social skills. The students will use which one of the most widely used screening tests?
- A. Revised Prescreening Developmental Questionnaire
- B. Goodenough Draw-a-Person Screening Test
- C. Denver Developmental Screening Test
- D. Caldwell Home Inventory
Correct Answer: C
Rationale: The Revised Prescreening Developmental Questionnaire is more age appropriate and offers simplified parent scoring and easier comparison. It is used by parents instead of professionals. The Goodenough Draw-a-Person test is used to assess intellectual development. The Denver Developmental Screening Test is one of the most widely used screening tests. It offers a concise, easy-to-administer, systematic approach to assessing the preschool child. It is widely used because of its reliability and validity. The Caldwell Home Inventory is used to assess the home environment in areas of social, emotional, and cognitive supports.
A female client has been hospitalized for several months following major abdominal surgery for a ruptured colon. A colostomy was created, and the large abdominal wound was left open and allowed to heal through granulation. She is receiving gentamicin IV for treatment of wound infection. Knowing this drug is ototoxic, the nurse would implement which of the following measures?
- A. Instruct the client to report any signs of tinnitus, dizziness or difficulty hearing.
- B. Advise the client to discontinue the drug at the first sign of dizziness.
- C. Order audiometric testing in order to determine if hearing loss is caused by an ototoxic drug or other cause.
- D. Instruct the client in Valsalva's maneuver to equalize middle ear pressure and to prevent hearing loss.
Correct Answer: A
Rationale: The first nursing measure is to instruct the client in which drug side effects to report. Discontinuing the drug is not an independent nursing intervention and may compromise client care. Audiometric testing will detect hearing loss, but it does not indicate a potential cause. Equalizing middle ear pressure will not prevent hearing loss.
Which newborn assessment is considered an abnormal finding that requires immediate attention?
- A. Cyanosis of the hands and feet
- B. Umbilical stump with three vessels
- C. Jitteriness and shaking
- D. Presence of harlequin sign
Correct Answer: C
Rationale: Jitteriness and shaking in a newborn may indicate hypoglycemia seizures or neurological issues requiring immediate attention. Cyanosis of hands and feet (acrocyanosis) three umbilical vessels and harlequin sign are normal or benign findings.
The medication that best penetrates eschar is:
- A. Mafenide acetate (Sulfamylon)
- B. Silver sulfadiazine (Silvadene)
- C. Neomycin sulfate (Neosporin)
- D. Povidone-iodine (Betadine)
Correct Answer: A
Rationale: Mafenide acetate is bacteriostatic and best penetrates eschar, making it effective for deep burn wounds. The other medications do not penetrate eschar as effectively.
The nurse is assessing elderly clients at a community center.
- A. Dry mouth
- B. Loss of one inch of height in the last year
- C. Stiffened joints
- D. Rales bilaterally on chest auscultation
Correct Answer: D
Rationale: Rales bilaterally indicate possible pulmonary edema or infection, which are serious conditions requiring immediate attention. Dry mouth (A), height loss (B), and stiffened joints (C) are common in aging but less urgent.