Nokea
A nurse sees documentation in the client's record indicating that the health care provider has noted the presence of adventitious breath sounds. The nurse knows that these types of sounds have which aspect?
- A. Normally heard in the lungs
- B. Hollow sounds heard over the trachea and larynx
- C. Rustling sounds heard over the peripheral lung fields
- D. Abnormal sounds that should not be heard in the lungs
Correct Answer: D
Rationale: Adventitious breath sounds are abnormal sounds that are not normally heard in the lungs. These sounds are added sounds superimposed on the breath sounds. They are caused by air colliding with secretions in the tracheobronchial passageways or when previously deflated airways pop open. Hollow sounds heard over the trachea and larynx are normal bronchial (tracheal) breath sounds, not adventitious. Rustling sounds heard over the peripheral lung fields are normal vesicular breath sounds, not adventitious. Therefore, the correct answer is that adventitious breath sounds are abnormal sounds that should not be heard in the lungs.
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A day care center has asked the nurse to provide education for parents regarding safety in the home. What type of preventive care does this represent?
- A. Primary
- B. Secondary
- C. Tertiary
- D. Health promotion
Correct Answer: A
Rationale: Primary prevention involves activities that promote wellness or prevent illness or injury. Educating parents about safety measures in the home aims to prevent injuries, making it a primary prevention strategy. Secondary prevention focuses on early detection and intervention in diseases or injuries. Tertiary prevention involves reducing disability and promoting optimal functioning in relation to a disease or injury. Health promotion encompasses activities that enhance a client's overall health and well-being. In this scenario, educating parents about safety in the home falls under primary prevention as it aims to prevent injuries before they occur.
The LPN has been asked to help a client taking Risperdal with activities of daily living in the morning. Which of these tasks is most likely to be potentially impacted by this medication?
- A. eating breakfast
- B. drinking fluids
- C. getting out of bed to use the bathroom
- D. brushing teeth
Correct Answer: C
Rationale: The correct answer is 'getting out of bed to use the bathroom.' Risperdal can cause orthostatic hypotension, leading to a drop in blood pressure when changing positions from lying down to standing up. This effect increases the risk of falls, emphasizing the need to assist the client with this task to prevent potential harm. Choices A, B, and D are less likely to be directly impacted by the medication, unlike the significant risk of orthostatic hypotension associated with changing positions.
The school nurse is conducting health screenings on schoolchildren. During the screening, she identifies a child with the behavioral characteristics of attention deficit disorder. Which of the following behaviors is consistent with this disorder?
- A. slow speech development
- B. overreaction to stimuli from the surroundings
- C. inability to carry on a conversation
- D. concrete thinking
Correct Answer: B
Rationale: The correct answer is 'overreaction to stimuli from the surroundings.' Children with attention deficit disorder often exhibit hypersensitivity to stimuli, leading to overreactions. Slow speech development is not a hallmark of attention deficit disorder; it is more associated with other learning disabilities. While children with this disorder may have difficulty focusing, they can usually carry on a conversation. Concrete thinking is not a common characteristic of attention deficit disorder, as individuals with this disorder may struggle with abstract thinking and impulsivity.
A pregnant client asks how she can prevent getting Group B Strep. What is the LPN's best response?
- A. You cannot prevent getting Group B Strep; you can only treat it.
- B. You should have your partner wear a condom every time you have intercourse.
- C. You should be extra vigilant about hand-washing, especially in the third trimester.
- D. The Group B Strep vaccine is the only proven way to prevent the disease.
Correct Answer: A
Rationale: The best response for the LPN to provide to a pregnant client concerned about preventing Group B Strep is that it cannot be prevented, only treated. Group B Strep is a normal flora found in the vagina, rectum, and intestines of about 25% of women and is not a sexually transmitted disease. Testing for Group B Strep is done in each pregnancy, usually around 35-37 weeks. If a woman tests positive, antibiotics are administered during labor to reduce the risk of complications for both the mother and the baby. Choice A is the correct answer as Group B Strep cannot be prevented but only treated. Choice B is incorrect; condom use does not prevent Group B Strep. Choice C is not the best response as hand-washing is important for general hygiene but does not specifically prevent Group B Strep. Choice D is incorrect as there is no vaccine available to prevent Group B Strep.
A healthcare professional is using an otoscope to inspect the ears of an adult client. Which action does the professional take before inserting the otoscope?
- A. Pulling the pinna up and back
- B. Pulling the pinna down and forward
- C. Tipping the client's head down and toward the examiner
- D. Tipping the client's head down and away from the examiner
Correct Answer: A
Rationale: In an adult client, the healthcare professional should pull the pinna up and back before inserting the otoscope. This action helps straighten the S shape of the ear canal, making it easier to insert the otoscope directly and comfortably. Tipping the client's head down and toward or away from the examiner is not the correct action when using an otoscope in an adult. Pulling the pinna down and forward is typically done when examining an infant or a child younger than 3 years old to straighten their ear canal for better visualization.