Nokea
A nurse is collecting data from a client who has Bell's palsy. Which of the following findings should the nurse expect? (Select all that apply.)
- A. Muscle distortion
- B. Pain behind the ear
- C. Hearing loss
- D. Facial twitching
- E. Impaired taste
Correct Answer: A,B,E
Rationale: The correct findings for a client with Bell's palsy are muscle distortion, pain behind the ear, and impaired taste. Muscle distortion occurs due to facial nerve paralysis, leading to drooping or weakness on one side of the face. Pain behind the ear can result from inflammation of the facial nerve. Impaired taste can occur due to dysfunction of the taste buds innervated by the facial nerve. Hearing loss (C) is not typically associated with Bell's palsy. Facial twitching (D) may occur in other conditions like hemifacial spasm but not a defining feature of Bell's palsy.
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A nurse is collecting data about a client's cardiac functioning. The nurse auscultates an S3 sound. Which of the following causes should the nurse suspect?
- A. Atrial gallop
- B. Ventricular gallop
- C. Closing of the atrioventricular valves
- D. Closing of semilunar valves
Correct Answer: B
Rationale: The correct answer is B: Ventricular gallop. An S3 heart sound is indicative of rapid ventricular filling during diastole, which is commonly associated with heart failure. This sound occurs during the early phase of diastole when the ventricles are filled rapidly due to increased pressure in the atria. The S3 sound is heard immediately after S2 (closure of semilunar valves) when blood is rushing into the ventricles. Atrial gallop (choice A) is not associated with the S3 sound. The closing of the atrioventricular valves (choice C) is part of the normal heart sounds and does not produce an S3 sound. Similarly, the closing of semilunar valves (choice D) occurs during S2 but does not cause an S3 sound. Therefore, the correct answer is B as it directly relates to the pathophysiology of an S3 heart sound.
A nurse is planning home care for a school-age child who is awaiting discharge to home following an acute asthma attack. Which of the following growth and development stages according to Erikson should the nurse consider in the planning?
- A. Autonomy vs. shame and doubt
- B. Initiative vs. guilt
- C. Industry vs. inferiority
- D. Identity vs. role confusion
Correct Answer: C
Rationale: The correct answer is C: Industry vs. inferiority. In Erikson's psychosocial development theory, school-age children (around 6-12 years old) are in the stage of industry vs. inferiority. During this stage, children seek to develop a sense of competence and accomplishment by mastering new skills and tasks. This is crucial to consider in planning home care for a child recovering from an acute asthma attack as fostering a sense of industry can positively impact their self-esteem and motivation to manage their health.
Choice A: Autonomy vs. shame and doubt is more relevant to toddlers, not school-age children. Choice B: Initiative vs. guilt is about preschoolers. Choice D: Identity vs. role confusion is for adolescents. Choices E, F, G are not provided, but they would not be relevant to the developmental stage of school-age children.
A nurse is reinforcing dietary teaching with a client who is Asian-American and looks at the floor during the instruction. Which of the following actions should the nurse take to demonstrate cultural sensitivity?
- A. Check to see what is on the floor.
- B. Pause and wait until the client looks up.
- C. Move closer to the client.
- D. Continue the discussion while avoiding eye contact.
Correct Answer: D
Rationale: Avoiding direct eye contact is a cultural sign of respect in some Asian cultures, so the nurse should not force eye contact.
A charge nurse is assisting a newly-licensed nurse to insert an indwelling urinary catheter for a male client. Which of the following actions requires the charge nurse to intervene?
- A. Lubricates the first 2.5 to 5 cm (1 to 2 in) of the catheter tubing
- B. Lubricates the first 15 to 17.5 cm (6 to 7 in) of the catheter
- C. Secures the tubing to the client's upper thigh
- D. Secures the tubing to the client's lower abdomen.
Correct Answer: A
Rationale: Correct Answer: A
Rationale: The correct action for inserting an indwelling urinary catheter in a male client is to lubricate the first 15 to 17.5 cm (6 to 7 in) of the catheter, not just the first 2.5 to 5 cm (1 to 2 in). This is crucial to ensure smooth insertion and prevent trauma to the urethra. Therefore, the charge nurse should intervene and guide the newly-licensed nurse to lubricate the appropriate length of the catheter tubing.
Summary of Incorrect Choices:
B: Lubricating the first 15 to 17.5 cm (6 to 7 in) of the catheter is the correct action, not an intervention.
C: Securing the tubing to the client's upper thigh is a proper step to prevent pulling on the catheter, not requiring intervention.
D: Securing the tubing to the client's lower abdomen is also a standard practice to prevent dislod
A nurse is caring for an older adult client who is Chinese and is recovering from a bowel obstruction. The client is prescribed a clear-liquid diet and asks the nurse for a cup of hot ginger tea. The nurse should identify that this request is for which of the following purposes?
- A. To regulate blood pressure
- B. To promote digestion
- C. To enhance the immune system
- D. To reduce inflammation
Correct Answer: B
Rationale: The correct answer is B: To promote digestion. Ginger tea has been traditionally used in Chinese medicine to aid digestion by stimulating the production of digestive enzymes and reducing bloating and gas. This can be particularly beneficial for an older adult recovering from a bowel obstruction as it can help ease the digestive process and prevent further complications. Additionally, ginger has anti-inflammatory properties, which can also be helpful in reducing inflammation in the digestive tract.
Other choices are incorrect:
A: To regulate blood pressure - While ginger may have some benefits for heart health, its primary role in this scenario is to aid digestion, not regulate blood pressure.
C: To enhance the immune system - While ginger may have some immune-boosting properties, the primary reason for the client's request in this case is to aid digestion.
D: To reduce inflammation - While ginger does have anti-inflammatory properties, the main purpose of the client's request is to aid digestion rather than specifically targeting inflammation.