Nokea
A nurse in a family practice clinic is preparing discharge instructions for a client reporting facial pain that is worse when bending over tenderness across the cheeks and postnasal discharge. What instruction will be most helpful?
- A. Ice packs may help with the facial pain.
- B. Limit fluids to dry out your sinuses.
- C. Try warm, moist heat packs on your face.
- D. We will schedule a computed tomography scan this week.
Correct Answer: C
Rationale: The correct answer is C: Try warm, moist heat packs on your face. Warm, moist heat can help relieve facial pain and sinus pressure by promoting sinus drainage and reducing inflammation. Ice packs may not be as effective for this type of pain. Limiting fluids can worsen symptoms by drying out the sinuses. Scheduling a CT scan is not necessary at this point as the symptoms described are indicative of sinusitis, which can often be managed with conservative measures like warm compresses.
You may also like to solve these questions
A client who is human immunodeficiency virus-positive has had a Mantoux skin test. The nurse notes a 7-mm area of induration at the site of the skin test. The nurse interprets the results as:
- A. Positive
- B. Negative
- C. Inconclusive
- D. Indicating the need for repeat testing.
Correct Answer: A
Rationale: The correct answer is A: Positive. In individuals with HIV, a positive Mantoux test is considered when the induration is 5 mm or greater. A 7-mm area of induration indicates a positive result, suggesting an immune response to the tuberculin antigen, potentially due to latent tuberculosis infection. The other choices are incorrect because a 7-mm induration in an HIV-positive client is not considered negative, inconclusive, or indicative of the need for repeat testing based on current guidelines.
The nurse is performing a respiratory assessment of a patient who has been experiencing episodes of hypoxia. The nurse is aware that this is ultimately attributable to impaired gas exchange. On what factor does adequate gas exchange primarily depend?
- A. An appropriate perfusion-diffusion ratio
- B. An adequate ventilation-perfusion ratio
- C. Adequate diffusion of gas in shunted blood
- D. Appropriate blood nitrogen concentration
Correct Answer: B
Rationale: The correct answer is B: An adequate ventilation-perfusion ratio. Adequate gas exchange primarily depends on the matching of ventilation (air reaching the alveoli) and perfusion (blood flow to the alveoli). A mismatch in this ratio can lead to impaired gas exchange, resulting in hypoxia. Option A relates to gas movement efficiency but does not address the matching of ventilation and perfusion. Option C mentions shunted blood, which is not directly related to the ventilation-perfusion ratio. Option D is unrelated to gas exchange. In summary, the ventilation-perfusion ratio is crucial for optimal gas exchange, making it the correct choice.
Which nursing activity is most important to include in the client's care?
- A. Perform postural drainage and chest physiotherapy every 4 hours.
- B. Discuss client's feelings about the need for a living will.
- C. Place in private room to decrease the risk of further infection.
- D. Plan activities to allow at least 8 hours of uninterrupted sleep.
Correct Answer: A
Rationale: The correct answer is A. Postural drainage and chest physiotherapy are critical for clearing secretions and improving lung function in cystic fibrosis. Discussing a living will (B), isolation (C), and sleep planning (D) are less urgent.
A male patient has chronic obstructive pulmonary disease (COPD) and is a smoker. The nurse notices respiratory distress and no breath sounds over the left chest. Which type of pneumothorax should the nurse suspect is occurring?
- A. Tension pneumothorax
- B. Iatrogenic pneumothorax
- C. Traumatic pneumothorax
- D. Spontaneous pneumothorax
Correct Answer: D
Rationale: In this scenario, the patient has a history of COPD and is a smoker, making spontaneous pneumothorax more likely. Spontaneous pneumothorax occurs without any trauma or injury and is often seen in patients with underlying lung conditions like COPD.
The nurse is preparing a presentation that highlights the benefits of annual influenza vaccination. The nurse correctly targets which groups Except?
- A. Parents of children 3 to 6 months of age.
- B. Diabetics who are over 50 years old.
- C. Pregnant women.
- D. Home health aides.
Correct Answer: A
Rationale: The correct answer is A because children aged 3 to 6 months are too young to receive the influenza vaccine. They are not recommended for vaccination until they reach 6 months of age. Choice B is correct as older diabetics are at higher risk for complications from the flu. Choice C is correct as pregnant women are a high-risk group for flu-related complications. Choice D is correct as home health aides are in close contact with vulnerable populations.