Nokea
A normal, healthy 35-year-old male client visits the doctor's office for a routine annual physical. When auscultating between the first and second interspaces on the anterior chest, the nurse anticipates which type of breath sound?
- A. bronchovesicular
- B. vesicular
- C. bronchial
- D. tracheal
Correct Answer: A
Rationale: Bronchovesicular sounds are expected between the first and second interspaces, where major bronchi and alveoli are near.
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A client is given a prescription for an antipsychotic medication. The nurse instructs the client and family to report any signs/symptoms of pseudoparkinsonism and tells the family to monitor for what effects indicative of this medication complication?
- A. Tremors and hyperpyrexia
- B. Motor restlessness and aphasia
- C. Stooped posture and a shuffling gait
- D. Muscle weakness and decreased salivation
Correct Answer: C
Rationale: Pseudoparkinsonism is a common extrapyramidal side effect of antipsychotic medications. This condition is characterized by a stooped posture, a shuffling gait, a masklike facial appearance, drooling, tremors, and pill-rolling motions of the fingers. Hyperpyrexia is characteristic of the extrapyramidal side effect of neuroleptic malignant syndrome. Motor restlessness, aphasia, muscle weakness, and decreased salivation are not characteristic of pseudoparkinsonism.
The nurse provides home care instructions to a client who has been diagnosed with recurrent trichomoniasis. The nurse determines the need for follow-up teaching if the client indicates she should take which action?
- A. Avoid sexual intercourse.
- B. Perform good perineal hygiene.
- C. Use the metronidazole as prescribed.
- D. Discontinue treatment during menstruation.
Correct Answer: D
Rationale: Treatment for a recurrent vaginal trichomoniasis infection continues through the menstrual period because the vagina is more alkaline during menses, and a flare-up is more likely to occur. While the infection remains active, the client should refrain from sexual intercourse or instruct her partner to wear a condom. To help break the chain of infection, the nurse directs the client to perform perineal hygiene after each voiding and each bowel movement. Metronidazole must be taken as prescribed.
The nurse is developing goals for the postpartum client who is at risk for uterine infection. Which goal is most appropriate for this client?
- A. The client will verbalize a reduction of pain.
- B. The client will report how to treat an infection.
- C. The client will be able to identify measures to prevent infection.
- D. The client will identify the presence of Braxton Hicks contractions.
Correct Answer: C
Rationale: The uterus is theoretically sterile during pregnancy until the membranes rupture. However, it is capable of being invaded by pathogens after membrane rupture. The reduction of pain and Braxton Hicks contractions that occur during pregnancy are unrelated to the subject of infection. Reporting the treatment of infection indicates that an infection is present. Preventing an infection is a goal for the client who is at risk for infection.
The community health is conducting a health screening clinic. The nurse interprets that which client participating in the screening is the highest priority client to provide instruction to lower the risk of developing respiratory disease?
- A. A smoker who works in an acute care hospital
- B. A person who works with lawn care pesticides
- C. A person who does woodworking as a hobby for 8 years
- D. A smoker who has cracked asbestos lining on the basement pipes
Correct Answer: D
Rationale: The client who smokes and has exposure to cracked asbestos lining is at the highest risk for respiratory disease due to the combined effects of smoking and asbestos, both potent lung irritants. Smoking alone or other exposures (pesticides, woodworking) pose risks, but the dual exposure in option D is the most severe.
The nurse teaches a client diagnosed with a spinal cord injury about measures to prevent autonomic hyperreflexia. Which statement by the client indicates the need for additional teaching?
- A. It is best if I avoid tight clothing and lumpy bedclothes.
- B. I should watch for headache, congestion, and flushed skin.
- C. Signs/symptoms I should watch for include fever and chest pain.
- D. I need to pay close attention to how frequently my bowels move.
Correct Answer: C
Rationale: Autonomic hyperreflexia generally occurs in a client with a spinal cord injury after the period of spinal shock resolves. It occurs with injuries above T6 and cervical injuries. Signs/symptoms of autonomic hyperreflexia include headache, congestion, flushed skin above the level of injury and cold skin below it, diaphoresis, nausea, and anxiety. Fever and chest pain are not associated with this condition.