Nokea
A nurse working in a geriatric clinic sees clients with "cold" symptoms and rhinitis. The primary health care provider (PHCP) often leaves a prescription for diphenhydramine. What action by the nurse is best?
- A. Teach the client about possible drowsiness.
- B. Instruct the client to drink plenty of water.
- C. Consult with the PHCP about the medication.
- D. Encourage the client to take the medication with food.
Correct Answer: C
Rationale: The correct answer is C: Consult with the PHCP about the medication. This is the best action because diphenhydramine may not be the most appropriate medication for older adults due to potential side effects like increased risk of falls, confusion, and urinary retention. Consulting with the PHCP will ensure that the medication is safe and effective for the client.
A: Teaching about drowsiness is important but not the priority.
B: Drinking water is generally good advice but not specific to diphenhydramine.
D: Taking medication with food can help reduce stomach upset but doesn't address the concerns related to diphenhydramine in older adults.
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Blessy, a community health nurse is conducting an educational session with community members regarding tuberculosis. The nurse tells the group that one of the first symptoms associated with tuberculosis is:
- A. Dyspnea
- B. Chest pain
- C. A bloody, productive cough.
- D. Bronchoscopy
Correct Answer: B
Rationale: The correct answer is B: Chest pain. Chest pain can be one of the first symptoms of tuberculosis due to inflammation of the lung tissue or pleura. Dyspnea (A) typically occurs in later stages as the disease progresses. A bloody, productive cough (C) is a common symptom of tuberculosis but may not be one of the first symptoms. Bronchoscopy (D) is a diagnostic procedure and not a symptom of tuberculosis. In summary, chest pain is a common initial symptom due to lung inflammation, while the other choices are either later symptoms or unrelated diagnostic procedures.
A nurse observes that a client's anteroposterior (AP) chest diameter is the same as the lateral chest diameter. Which question should the nurse ask the client in response to this finding?
- A. Are you taking any medications or herbal supplements?
- B. Do you have any chronic breathing problems?
- C. How often do you perform aerobic exercise?
- D. What is your occupation and what are your hobbies?
Correct Answer: B
Rationale: The correct answer is B: Do you have any chronic breathing problems? This question is relevant because equal AP and lateral chest diameters can indicate a condition called barrel chest, often associated with chronic obstructive pulmonary disease (COPD). Clients with COPD may have increased chest diameters due to air trapping. Asking about chronic breathing problems can help the nurse further assess the client's respiratory status.
Choice A is incorrect because medications or herbal supplements are not directly related to equal AP and lateral chest diameters. Choice C is incorrect as aerobic exercise frequency does not typically impact chest diameters in this manner. Choice D is also incorrect as occupation and hobbies are not likely to be directly linked to equal chest diameters.
Which of the following is a sign or symptom of asthma?
- A. Production of abnormally thick
- B. sticky mucus in lungs
- C. Faulty transport of sodium in lung cells
- D. Paroxysms or shortness of breath
Correct Answer: C
Rationale: The correct answer is C. Paroxysms of shortness of breath are classic symptoms of asthma. A (thick mucus) is associated with cystic fibrosis. B (faulty sodium transport) relates to cystic fibrosis. D (altered electrolytes) is unrelated to asthma.
Which action should you take next?
- A. Reassure the client that the ventilator will do the work of breathing for her.
- B. Manually ventilate the client while you assess possible reasons for the high pressure alarm.
- C. Increase the FiO2 on the ventilator to 100% in preparation for endotracheal suctioning.
- D. Insert an oral airway to prevent the client from biting on the endotracheal tube.
Correct Answer: B
Rationale: The correct answer is B. High pressure alarms and desaturation require immediate manual ventilation and assessment for causes. Reassurance (A) is insufficient. Increasing FiO2 (C) and inserting an oral airway (D) are secondary actions.
Phrenic nerve are
- A. in diaphragmatic area
- B. at c3 to c5
- C. Both A and B
- D. non
Correct Answer: C
Rationale: The phrenic nerve innervates the diaphragm and arises from cervical nerve roots C3 to C5. Choice C is correct as it accurately states that the phrenic nerve is located in the diaphragmatic area and originates from C3 to C5. Choice A is incorrect as it only mentions the diaphragmatic area without specifying the cervical levels. Choice B is incorrect as it only mentions the cervical levels without specifying the diaphragmatic area. Choice D is incorrect as the phrenic nerve does exist.