Nokea
A nurse is caring for a client with lung cancer who is experiencing dyspnea. Which intervention is most appropriate?
- A. Administer a cough suppressant to reduce discomfort.
- B. Encourage the client to lie flat to ease breathing.
- C. Provide supplemental oxygen therapy.
- D. Encourage deep breathing and coughing exercises.
Correct Answer: C
Rationale: The most appropriate intervention for a client with lung cancer experiencing dyspnea is to provide supplemental oxygen therapy. This intervention helps improve oxygenation and alleviate breathing difficulties. Administering a cough suppressant (Choice A) may not address the underlying cause of dyspnea and can potentially depress the respiratory drive. Encouraging the client to lie flat (Choice B) can worsen dyspnea by reducing lung expansion. Encouraging deep breathing and coughing exercises (Choice D) may be beneficial in some situations, but when a client is experiencing dyspnea due to lung cancer, supplemental oxygen therapy is the priority to improve oxygen levels and alleviate breathing difficulty.
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After teaching the students about B cells, which statement indicates teaching was successful? B cells are originally derived from cells of the:
- A. Bone marrow
- B. Lymph nodes
- C. Gut-associated lymphoid tissue
- D. Thymus
Correct Answer: A
Rationale: The correct answer is A: Bone marrow. B cells are originally derived from cells of the bone marrow. Bone marrow is the primary site where B cells develop and mature. Lymph nodes (choice B), gut-associated lymphoid tissue (choice C), and the thymus (choice D) are involved in the immune response but are not the primary site of origin for B cells.
A nurse working in a busy orthopedic clinic is asked to perform the Tinel sign on a client having problems in her hand/wrist. In order to test Tinel sign, the nurse should give the client which direction?
- A. Stand tall, arms at your side, shut your eyes; place the tip of your index finger to your nose.
- B. Hold your wrist in complete flexion, keep it in this position for 60 seconds. How does your hand feel after placing it in a neutral position?
- C. I'm going to tap (percuss) over the median nerve in your wrist; tell me what sensation you feel while I am doing this. Does the sensation stay in the wrist or go anywhere else?
- D. I'm going to tap this tuning fork; place it on the side of your thumb, then tell me what you are feeling in your hand and wrist.
Correct Answer: C
Rationale: The correct answer is C. The Tinel sign involves percussing over the median nerve in the wrist to test for carpal tunnel syndrome. Choice A is incorrect as it describes a different action unrelated to the Tinel sign. Choice B is also incorrect as it involves holding the wrist in flexion, which is not part of the Tinel sign assessment. Choice D is incorrect as it mentions using a tuning fork on the thumb, which is not the correct technique for assessing the Tinel sign.
Which of the following describes the damage to the brain that results in cerebral palsy?
- A. Reversible with cognitive therapy in infancy
- B. Transient and resolves in adulthood through physical therapy
- C. Manifests in adulthood after regular childhood activities
- D. Irreversible and occurs before, during, or after birth or infancy
Correct Answer: D
Rationale: The correct answer is D. Cerebral palsy involves irreversible damage to the brain that occurs before, during, or shortly after birth, impacting movement and coordination. Choices A, B, and C are incorrect because cerebral palsy is not reversible with cognitive therapy or physical therapy, does not resolve in adulthood, and does not manifest in adulthood after regular childhood activities.
A 21-year-old female was recently diagnosed with iron deficiency anemia. In addition to fatigue and weakness, which of the following clinical signs and symptoms would she most likely exhibit?
- A. Hyperactivity
- B. Spoon-shaped nails
- C. Gait problems
- D. Petechiae
Correct Answer: B
Rationale: The correct answer is B: Spoon-shaped nails. In iron deficiency anemia, spoon-shaped nails (koilonychia) are a common symptom due to changes in the nail bed. This condition is known as Plummer-Vinson syndrome. While fatigue and weakness are common in iron deficiency anemia, hyperactivity (choice A) is not typically associated with this condition. Gait problems (choice C) and petechiae (choice D) are more commonly seen in other medical conditions and are not characteristic of iron deficiency anemia.
A patient has been prescribed conjugated estrogens for the treatment of menopausal symptoms. What should the nurse include in the patient teaching?
- A. Increase the intake of calcium-rich foods.
- B. Decrease the intake of high-fat foods.
- C. Avoid the use of tobacco.
- D. Avoid exposure to sunlight.
Correct Answer: A
Rationale: The correct answer is A: Increase the intake of calcium-rich foods. Patients taking conjugated estrogens should increase their intake of calcium-rich foods to help prevent osteoporosis. Estrogen therapy can lead to an increased risk of osteoporosis, so ensuring an adequate intake of calcium is crucial. Choices B, decreasing high-fat foods, and C, avoiding tobacco, are general health recommendations but not directly related to the prescription of conjugated estrogens. Choice D, avoiding exposure to sunlight, is not a direct concern when taking conjugated estrogens.