Nokea
After assessing Mr. B, what is the initial action of the nurse?
- A. Immediately place the client in a negative-pressure room
- B. Set the client up to receive a bronchoscopy
- C. Contact the physician for antifungal medications
- D. Administer oxygen and assist the client to sit in the semi-Fowler's position
Correct Answer: A
Rationale: The first action the nurse should take after assessing Mr. B is to administer oxygen and assist him to sit in the semi-Fowler's position. Administering oxygen helps improve tissue oxygenation, while sitting up in a semi-Fowler's position aids in better breathing and secretion clearance. Placing the client in a negative-pressure room is not the immediate priority unless isolation is needed. Performing a bronchoscopy or contacting the physician for antifungal medications is not the initial step in managing a client with suspected pneumonia.
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A child is seen in the emergency department for scarlet fever. Which of the following descriptions of scarlet fever is not correct?
- A. Scarlet fever is caused by infection with group A Streptococcus bacteria.
- B. "Strawberry tongue"? is a characteristic sign.
- C. Petechiae occur on the soft palate.
- D. The pharynx is red and swollen.
Correct Answer: C
Rationale: Petechiae on the soft palate are not a typical finding in scarlet fever. Scarlet fever is caused by group A Streptococcus bacteria, often presenting with a strawberry tongue, red and swollen pharynx, and a sandpaper-like rash. The presence of petechiae on the soft palate is more commonly associated with conditions like rubella rather than scarlet fever. Therefore, this description is not correct in the context of scarlet fever.
In a pediatric clinic, a nurse is assessing a child recently diagnosed with cystic fibrosis. Which of the following later findings of this disease would the nurse not expect to see at this time?
- A. Positive sweat test
- B. Bulky greasy stools
- C. Moist, productive cough
- D. Meconium ileus
Correct Answer: C
Rationale: In a child newly diagnosed with cystic fibrosis (CF), noisy respirations and a dry, non-productive cough are typically the first respiratory signs to appear. The other options, including a positive sweat test, bulky greasy stools, and meconium ileus, are among the earliest findings of CF. CF is a genetic condition that affects the production of mucus, sweat, saliva, and digestive juices. Due to a defective gene, these secretions become thick and sticky instead of thin and slippery, leading to blockages in various passageways, especially in the pancreas and lungs. Respiratory failure is a severe consequence of CF, making it crucial to monitor respiratory symptoms closely in affected individuals. Therefore, a moist, productive cough would not be an expected finding in a newly diagnosed child with CF.
A healthcare provider calls a physician with the concern that a patient has developed a pulmonary embolism. Which of the following symptoms has the healthcare provider most likely observed?
- A. The patient is somnolent with decreased response to stimuli.
- B. The patient suddenly complains of chest pain and shortness of breath.
- C. The patient has developed a wet cough and the healthcare provider hears crackles on auscultation of the lungs.
- D. The patient has a fever, chills, and loss of appetite.
Correct Answer: B
Rationale: The correct answer is 'The patient suddenly complains of chest pain and shortness of breath.' Typical symptoms of pulmonary embolism include chest pain, shortness of breath, and severe anxiety. The physician should be notified immediately. Clinical signs and symptoms for pulmonary embolism are nonspecific; therefore, patients suspected of having pulmonary embolism"?because of unexplained dyspnea, tachypnea, or chest pain or the presence of risk factors for pulmonary embolism"?must undergo diagnostic tests until the diagnosis is ascertained or eliminated or an alternative diagnosis is confirmed. Choices A, C, and D describe symptoms that are not typically associated with a pulmonary embolism, making them incorrect.
A healthcare provider is assessing vital signs in pediatric patients. Which of the following vital signs is abnormal?
- A. 11-year-old male: 90 BPM, 22 RPM, 100/70 mmHg
- B. 13-year-old female: 105 BPM, 22 RPM, 105/50 mmHg
- C. 5-year-old male: 102 BPM, 24 RPM, 90/65 mmHg
- D. 6-year-old female: 100 BPM, 26 RPM, 90/70 mmHg
Correct Answer: B
Rationale: The normal range of vital signs for pediatric patients varies with age. For 11 to 14-year-olds, the normal vital sign ranges are: Heart rate: 60-105 BPM; Respiratory rate: 12-20 RPM; Blood pressure: Systolic 85-120 mmHg, Diastolic 55-80 mmHg. The 13-year-old female in choice B has a diastolic blood pressure below the normal range, indicating hypotension. Additionally, her heart rate is at the upper limit of normal, and her respiratory rate is within normal limits. Choices A, C, and D all fall within the normal ranges for vital signs in pediatric patients.
A patient admitted to the hospital with myocardial infarction develops severe pulmonary edema. Which of the following symptoms should the nurse expect the patient to exhibit?
- A. Slow, deep respirations
- B. Stridor
- C. Bradycardia
- D. Air hunger
Correct Answer: D
Rationale: In a patient with pulmonary edema following a myocardial infarction, the nurse should expect symptoms such as air hunger, anxiety, and agitation. Air hunger refers to the feeling of needing to breathe more deeply or more often. Other symptoms of pulmonary edema can include coughing up blood or bloody froth, orthopnea (difficulty breathing when lying down), and paroxysmal nocturnal dyspnea (sudden awakening with shortness of breath). Slow, deep respirations (Choice A) are not typical in pulmonary edema; these patients often exhibit rapid, shallow breathing due to the difficulty in oxygen exchange. Stridor (Choice B) is a high-pitched breathing sound often associated with upper airway obstruction, not typically seen in pulmonary edema. Bradycardia (Choice C), a slow heart rate, is not a characteristic symptom of pulmonary edema, which is more likely to be associated with tachycardia due to the body's compensatory response to hypoxia and increased workload on the heart.