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During an abdominal examination, a nurse in a provider's office determines that a client has abdominal distention. The protrusion is at midline, the skin over the area is taut, and the nurse notes no involvement of the flanks. Which of the following possible causes of distention should the nurse suspect?
- A. Fat
- B. Fluid
- C. Flatus
- D. Hernias
Correct Answer: D
Rationale: The correct answer is 'Hernias.' Abdominal distention with a midline protrusion, taut skin, and no involvement of the flanks is characteristic of hernias. Hernias are caused by a weakness in the abdominal wall, allowing organs or tissues to protrude through. Fluid accumulation (ascites) typically presents with a more generalized distention, while fat accumulation may cause more diffuse distension rather than a focal midline protrusion. Flatus, or gas, would not typically present with a visible midline protrusion and taut skin like hernias.
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A client with stage IV lung cancer is 3 days postoperative following a wedge resection. The client states, "I told myself that I would go through with the surgery and quit smoking, if I could just live long enough to attend my child's wedding." Based on the Kubler-Ross model, which stage of grief is the client experiencing?
- A. Anger
- B. Denial
- C. Bargaining
- D. Acceptance
Correct Answer: C
Rationale: The client is in the bargaining stage of grief according to the Kubler-Ross model. In this stage, individuals negotiate for more time to achieve specific goals or fulfill desires. The client's statement about quitting smoking to attend their child's wedding reflects this bargaining behavior. Anger (choice A) is characterized by frustration and resentment, denial (choice B) involves avoidance of reality, and acceptance (choice D) signifies coming to terms with the situation, none of which align with the client's current mindset of bargaining.
When providing oral care to an unconscious patient, what action should the nurse take to protect the patient from injury?
- A. Moisten the mouth using lemon-glycerin sponges.
- B. Hold the patient's mouth open with gloved fingers.
- C. Use foam swabs to help remove plaque.
- D. Suction the oral cavity.
Correct Answer: D
Rationale: When caring for an unconscious patient, it is crucial to prevent choking and aspiration. Suctioning the oral cavity helps in removing secretions and preventing potential harm. Moisten the mouth using lemon-glycerin sponges may not effectively clear secretions. Holding the patient's mouth open with gloved fingers can cause discomfort and potential harm. Using foam swabs to remove plaque may not address the immediate risk of aspiration.
Which of the following should a group of community health nurses plan as part of a primary prevention program for occupational pulmonary diseases?
- A. Screening for early symptoms
- B. Providing treatment for diagnosed conditions
- C. Elimination of the exposure
- D. Increasing awareness of symptoms
Correct Answer: C
Rationale: The correct answer is C: 'Elimination of the exposure.' Primary prevention programs for occupational pulmonary diseases aim to prevent the development of these diseases by eliminating or minimizing exposure to harmful substances in the workplace. Screening for early symptoms (Choice A) focuses on secondary prevention, detecting diseases at an early stage. Providing treatment for diagnosed conditions (Choice B) is part of tertiary prevention, managing and treating established diseases. Increasing awareness of symptoms (Choice D) may help in early detection but does not directly address the prevention of exposure, which is crucial for primary prevention of occupational pulmonary diseases.
The pediatric clinic nurse examines a toddler with a tentative diagnosis of neuroblastoma. Findings observed by the nurse that are associated with this problem include which of these?
- A. Lymphedema and nerve palsy
- B. Hearing loss and ataxia
- C. Headaches and vomiting
- D. Abdominal mass and weakness
Correct Answer: D
Rationale: The correct answer is D: Abdominal mass and weakness. In neuroblastoma, the most common presenting signs are related to the mass effect of the tumor, leading to an abdominal mass and symptoms of weakness. Lymphedema and nerve palsy (Choice A) are not typically associated with neuroblastoma. Hearing loss and ataxia (Choice B) are more indicative of other conditions like neurofibromatosis or brain tumors. Headaches and vomiting (Choice C) are more commonly seen in conditions such as brain tumors or increased intracranial pressure, but they are not specific to neuroblastoma.
A nurse is reviewing the correct use of a fire extinguisher with a client. Which of the following actions should the nurse direct the client to take first?
- A. Remove the safety pin from the extinguisher.
- B. Aim the extinguisher at the base of the fire.
- C. Squeeze the handle to release the extinguishing agent.
- D. Sweep the extinguisher from side to side.
Correct Answer: A
Rationale: The correct first step in using a fire extinguisher is to remove the safety pin. This action enables the extinguisher to be activated and used effectively. Choice B, aiming the extinguisher at the base of the fire, comes after removing the safety pin. Choice C, squeezing the handle to release the extinguishing agent, and choice D, sweeping the extinguisher from side to side, are subsequent steps in using a fire extinguisher and should follow removing the safety pin.