Nokea
A nurse is assessing a patient's breath sounds. The patient has had a pneumonectomy to the right lung performed 48 hours ago. Which of the following conditions most likely exists?
- A. Decreased breath sound volume
- B. Elevated tidal volume
- C. Elevated respiratory capacity
- D. Wheezing
Correct Answer: A
Rationale: Breath sounds would be softer due to the removal of the right lung, reducing the area available for air exchange.
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A successful resolution of the nursing diagnosis Negative Self-Concept (related to unrealistic selfexpectations) is when the client can:
- A. report a positive self-concept.
- B. identify negative thoughts.
- C. recognize positive thoughts.
- D. give one positive cue with each negative cue.
Correct Answer: A
Rationale: The problem statement is Negative Self Concept. A successful resolution of the problem is when the client can report a positive self-concept. When the nurse determines how the client perceives himself, effort should be directed to reinforce self-worth and promote a positive self-concept, including helping a client to identify areas of strength. Assisting the client to evaluate himself and make behavior changes is a nursing intervention.
A client is assessed by the nurse as experiencing a crisis. The nurse plans to:
- A. allow the client to work through independent problem-solving.
- B. complete an in-depth evaluation of stressors and responses to the situation.
- C. focus on immediate stress reduction.
- D. recommend ongoing therapy.
Correct Answer: C
Rationale: A crisis is an acute, time-limited state of disequilibrium resulting from a situational, developmental, or societal source of stress. Utilizing the nursing process, the nurse should assist clients to work through a crisis to its resolution and restore their precrisis level of functioning.
An appropriate question when assessing a client's self-expectations about weight loss is:
- A. What makes you think you can change your eating habits?
- B. How do you feel about losing weight?
- C. How important is it that you lose weight?
- D. What do you think is a realistic weekly weight loss for you?
Correct Answer: D
Rationale: Nurses should assist clients to evaluate themselves and make behavior changes. Listening to clients, supporting clients' strengths, assisting clients to look at themselves in totality, and encouraging clients to set attainable goals should be part of the nurse-client relationship.
Herbal therapy has several indications for use. Primarily, herbal therapy is:
- A. used to treat many common complaints and diseases.
- B. used to promote certain types of low-carb diets.
- C. used as an adjunct to medications.
- D. used to create a diet without salt and carbohydrates.
Correct Answer: A
Rationale: Herbal therapy is used to treat many common complaints and diseases.
A 57-year-old woman is recently widowed. She states, 'I will never be able to learn how to manage the finances. My husband did all of that.' Select the nurse's response that could help raise the client's self-esteem.
- A. You feel inadequate because you have never learned to balance a checkbook.
- B. You should have insisted your husband teach you about the finances.
- C. You are strong and will learn how to manage your finances after awhile.
- D. Why don't you take a class in basic finance from the local college?
Correct Answer: C
Rationale: The nurse can raise the client's self-esteem by communicating confidence the client can participate in actively finding solutions to the problem. The nurse also conveys the client is a worthwhile person by listening and accepting the client's feelings and praising the client for seeking assistance.