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A nurse is caring for a client who has heart failure. Which of the following manifestations should the nurse expect?
- A. Crackles in lungs
- B. Decreased thirst
- C. Poor skin turgor
- D. Tachycardia
Correct Answer: A
Rationale: The correct answer is A: Crackles in lungs. In heart failure, the heart's inability to pump effectively leads to fluid accumulation in the lungs, causing crackles on auscultation. Decreased thirst (B) is not a typical manifestation. Poor skin turgor (C) is more indicative of dehydration. Tachycardia (D) may occur but is not specific to heart failure.
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A nurse is assessing a client who received hydromorphone 4 mg IV 15 min ago. The client has a respiratory rate of 10/min. The nurse should prepare to administer which of the following medications?
- A. Acetylcysteine
- B. Protamine
- C. Naloxone
- D. Flumazenil
Correct Answer: C
Rationale: The correct answer is C: Naloxone. Naloxone is an opioid antagonist used to reverse the effects of opioid overdose, such as respiratory depression. In this case, the client's respiratory rate of 10/min indicates opioid overdose due to hydromorphone. Naloxone administration can help reverse the respiratory depression and restore normal breathing.
Choice A: Acetylcysteine is used for acetaminophen overdose, not opioid overdose.
Choice B: Protamine is used to reverse the effects of heparin, not opioids.
Choice D: Flumazenil is a benzodiazepine antagonist, not an opioid antagonist.
Therefore, the most appropriate choice in this scenario is Naloxone to address the opioid overdose and respiratory depression.
A nurse is performing a neurological examination on a client as part of a complete physical assessment. The nurse should identify that cranial nerve XI is intact when the client performs which of the following actions?
- A. Shrugs his shoulders
- B. Sticks his tongue out
- C. Frowns symmetrically
- D. Identifies a sour taste
Correct Answer: A
Rationale: The correct answer is A: Shrugs his shoulders. Cranial nerve XI, also known as the spinal accessory nerve, is responsible for controlling the trapezius and sternocleidomastoid muscles, which are involved in shoulder shrugging. When the nurse asks the client to shrug his shoulders against resistance, she is testing the integrity of cranial nerve XI. This action allows the nurse to assess the strength and function of this particular cranial nerve.
Choices B, C, and D are incorrect because they test other cranial nerves. Sticking the tongue out (B) tests cranial nerve XII (hypoglossal nerve), frowning symmetrically (C) tests cranial nerve VII (facial nerve), and identifying a sour taste (D) tests cranial nerve IX (glossopharyngeal nerve). These actions do not involve cranial nerve XI and are therefore not indicators of its intactness.
A nurse is reading a tuberculin skin test for a client who received a purified protein derivative test 72 hr ago. Which of the following findings indicates a positive test?
- A. An induration measuring 10 mm
- B. An induration measuring 5 mm
- C. A reddened area measuring 10 mm
- D. A reddened area measuring 5 mm
Correct Answer: A
Rationale: The correct answer is A: An induration measuring 10 mm. An induration of 10 mm or greater is considered a positive result for a tuberculin skin test in individuals who are at higher risk for tuberculosis. This indicates exposure to the tuberculosis bacteria and an immune response. Choices B, C, and D are incorrect because the presence of redness or a smaller induration size does not meet the criteria for a positive test result. Redness alone does not signify a positive result, and a smaller induration size is not indicative of a positive test. It is important to interpret tuberculin skin tests accurately to guide further testing and treatment decisions.
For each assessment finding, click to specify if the finding is consistent with psychosis or mania. Each finding may support more than one diagnosis.
- A. Hallucinations
- B. Lack of sleep
- C. Excessive spending habits
- D. Disorganized thought process
- E. Pressured speech
Correct Answer: A: Psychosis; B, C, D, E: Mania
Rationale: The correct answer is A: Psychosis; B, C, D, E: Mania. Hallucinations are typically associated with psychosis due to perceptual disturbances. Lack of sleep, excessive spending habits, disorganized thought process, and pressured speech are all characteristic features of mania, which is a key symptom of Bipolar Disorder. Mania involves elevated mood, increased energy levels, impulsivity, and risky behavior, such as excessive spending. Disorganized thought process and pressured speech are manifestations of the racing thoughts and flight of ideas seen in mania. In summary, while hallucinations are consistent with psychosis, the other findings (lack of sleep, excessive spending habits, disorganized thought process, pressured speech) are more indicative of mania due to the presence of manic symptoms.
A nurse is preparing to admit a 6-year-old with varicella to the pediatric unit. Which of the following actions should the nurse take?
- A. Assign the child to a negative air pressure room.
- B. Administer aspirin to the child for fever.
- C. Use droplet precautions when caring for the child
- D. Assess the child for Koplik spots
Correct Answer: A
Rationale: Correct Answer: A - Assign the child to a negative air pressure room.
Rationale:
1. Varicella is highly contagious through airborne transmission.
2. Negative air pressure rooms help prevent the spread of infectious particles.
3. Isolation precautions are essential to protect other patients and healthcare workers.
4. Placing the child in a negative air pressure room minimizes the risk of transmission.
Summary of other choices:
B: Administering aspirin can lead to Reye's syndrome in children with varicella.
C: Droplet precautions are used for diseases like influenza, not varicella.
D: Koplik spots are associated with measles, not varicella.