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A healthcare professional is assisting with data collection of a client with suspected cholecystitis. Which finding does the healthcare professional expect to note if cholecystitis is present?
- A. Homan sign
- B. Murphy sign
- C. Blumberg sign
- D. McBurney sign
Correct Answer: B
Rationale: The correct answer is B: Murphy sign. The Murphy sign is an indicator of gallbladder disease. It involves the examiner placing fingers under the liver border while the client inhales. If the gallbladder is inflamed, it descends onto the fingers, causing pain. The Homan sign is associated with pain in the calf area upon sharp dorsiflexion of the foot, indicating deep vein thrombosis. The Blumberg sign is the presence of rebound tenderness on palpation of the abdomen, indicating peritoneal irritation. The McBurney sign is indicative of appendicitis, presenting as severe pain and tenderness upon palpation at McBurney's point in the right lower quadrant of the abdomen.
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A client who is experiencing infertility says to the nurse, 'I feel I will be incomplete as a man/woman if I cannot have a child.' Which of the following nursing diagnoses is likely to be appropriate for this client?
- A. Risk for Self-Harm
- B. Body Image Disturbance
- C. Ineffective Role Performance
- D. Powerlessness
Correct Answer: B
Rationale: The correct answer is 'Body Image Disturbance.' The client's statement reflects concerns about self-identity and completeness related to infertility, indicating a disturbance in body image perception. 'Risk for Self-Harm' is not the best choice as there is no indication of immediate self-harm. 'Ineffective Role Performance' is less appropriate since the statement does not directly relate to a disruption in the parent's role. 'Powerlessness' could be considered if the client expressed feelings of powerlessness specifically related to the infertility issue.
When performing the confrontation test to assess peripheral vision, what action should the nurse take?
- A. Asks the client to identify a small object brought into the visual field
- B. Has the client cover one eye while the nurse covers one eye and slowly advances a target midline between them
- C. Covers one eye, while the client covers the opposite eye, and brings a small object into the visual field
- D. Positions at eye level with the client, covers one eye, and has the client cover the opposite eye, then brings a small object into the visual field
Correct Answer: D
Rationale: When performing the confrontation test to assess peripheral vision, the nurse should position at eye level with the client, cover one eye, and have the client cover the opposite eye. This approach allows the examiner to bring a small object into the visual field to evaluate the client's peripheral vision. The test aims to compare the client's peripheral vision with the examiner's vision to identify any visual field deficits. Choices A, B, and C are incorrect. Choice A pertains to testing color vision, which is not part of the confrontation test. Choice B describes a different procedure that involves advancing a target midline between the client and examiner, not the correct approach for the confrontation test. Choice C is inaccurate as it fails to include the essential step of positioning at eye level with the client, making it an incorrect representation of the confrontation test.
While assisting with data collection, the client informs the nurse that he is having difficulty swallowing medications and food. The nurse gathers additional subjective data and documents that the client is experiencing which disorder?
- A. Pyrosis
- B. Anorexia
- C. Eructation
- D. Dysphagia
Correct Answer: D
Rationale: The correct answer is 'Dysphagia.' Dysphagia is the term used to indicate difficulty swallowing, which can occur in disorders of the throat or esophagus. Anorexia refers to a loss of appetite, not difficulty swallowing. Eructation is the medical term for belching, not difficulty swallowing. Pyrosis is heartburn, a burning sensation in the esophagus and stomach caused by the reflux of gastric acid, not difficulty swallowing.
Which of these medications is least likely to cause tinnitus?
- A. Aspirin
- B. Lasix
- C. Gentamicin
- D. Fluoxetine
Correct Answer: D
Rationale: The correct answer is Fluoxetine. Among the options provided, Fluoxetine is the medication least likely to cause tinnitus. Gentamicin, Lasix, and Aspirin are known ototoxic medications that have a potential side effect of causing tinnitus, a ringing in the ear. Gentamicin is an antibiotic, Lasix is a diuretic, and Aspirin is a common pain reliever that can lead to tinnitus. In contrast, Fluoxetine is a selective serotonin reuptake inhibitor (SSRI) primarily used as an antidepressant, and it has a lower risk of causing tinnitus compared to the other options.
In a community pediatric health clinic, which developmental task should you apply into your practice?
- A. You should apply the principles of initiative when caring for preschool children.
- B. You should apply the principles of sensorimotor thought when caring for preschool children.
- C. You should apply the principles of intimacy when caring for the adolescent.
- D. You should apply the principles of concrete operations when caring for the adolescent.
Correct Answer: A
Rationale: When working in a community pediatric health clinic, applying the principles of initiative is crucial when caring for preschool children. According to Erik Erikson's psychosocial theory, the developmental task for preschool children is initiative. Preschool children are in the stage where they are eager to initiate activities and carry out tasks. This stage is characterized by a balance between initiative and guilt. By encouraging children to explore and take the initiative in a supportive environment, healthcare providers can foster their sense of independence and creativity.
The other choices are incorrect because:
- Sensorimotor thought is a term associated with Jean Piaget's cognitive development theory, not Erikson's psychosocial theory.
- Intimacy is a developmental task associated with young adults, not adolescents, in Erikson's theory.
- Concrete operations is a term linked to Piaget's theory of cognitive development and is not a developmental task according to Erikson's psychosocial theory.