Nokea
During an assessment of an adult, the nurse has noted unequal chest expansion and recognizes that this occurs in which situation?
- A. In an obese patient.
- B. When part of the lung is obstructed or collapsed.
- C. When bulging of the intercostal spaces is present.
- D. When accessory muscles are used to augment respiratory effort.
Correct Answer: B
Rationale: The correct answer is B: When part of the lung is obstructed or collapsed. Unequal chest expansion can occur when there is an obstruction or collapse of a portion of the lung, leading to decreased lung expansion on that side. This can result in one side of the chest moving less during breathing. Other options are incorrect because: A: In an obese patient - obesity may affect chest wall movement but does not directly cause unequal chest expansion. C: When bulging of the intercostal spaces is present - bulging of intercostal spaces may indicate increased work of breathing but does not necessarily lead to unequal chest expansion. D: When accessory muscles are used to augment respiratory effort - while accessory muscles may be used in respiratory distress, they do not directly cause unequal chest expansion.
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In trying to communicate with a client with cerebral vascular accident (stroke) and aphasia, which of the following actions by the nurse would be least helpful to the client?
- A. Speaking to the client at a slower rate.
- B. Allowing plenty of time for the client to respond.
- C. Completing the sentences that the client cannot finish.
- D. Looking directly at the client during attempts at speech.
Correct Answer: C
Rationale: The correct answer is C because completing the client's sentences does not promote their communication skills development. It can be frustrating for the client and may hinder their progress in regaining speech abilities. A is correct because speaking slowly can help the client understand better. B is correct as it gives the client time to process and respond. D is correct as maintaining eye contact can enhance communication and show respect. Completing the client's sentences should be avoided as it undermines their autonomy and potential for improvement.
A 40-year-old woman presents with a complaint of frequent urination and increased thirst. She reports that these symptoms have been present for several weeks. She has a family history of diabetes mellitus. What is the most likely diagnosis?
- A. Diabetes mellitus
- B. Urinary tract infection
- C. Hypercalcemia
- D. Cystitis
Correct Answer: A
Rationale: The most likely diagnosis for the 40-year-old woman presenting with frequent urination, increased thirst, and a family history of diabetes mellitus is diabetes mellitus (Choice A).
1. Symptoms of frequent urination and increased thirst are classic signs of diabetes mellitus.
2. Family history of diabetes increases the likelihood of developing the condition.
3. Other choices are less likely:
- Urinary tract infection (Choice B) typically presents with symptoms such as pain or burning sensation during urination, fever, and cloudy urine.
- Hypercalcemia (Choice C) is characterized by elevated levels of calcium in the blood and is not directly related to the symptoms described.
- Cystitis (Choice D) is inflammation of the bladder and usually presents with symptoms like pain or discomfort in the pelvic area, frequent urination, and urgency to urinate.
In summary, based on the patient's symptoms and family history, diabetes mellitus is the most likely diagnosis, while the other choices
Which contraction generates the least force?
- A. Slow eccentric
- B. Fast eccentric
- C. Slow concentric
- D. Fast concentric
Correct Answer: D
Rationale: The correct answer is D: Fast concentric. Fast concentric contractions generate the least force because the muscle shortens quickly, leading to lower tension production compared to slow concentric contractions. In fast eccentric contractions (choice B), the muscle lengthens quickly, which can produce more force as it resists against gravity or an external load. Slow eccentric contractions (choice A) involve controlled lengthening of the muscle, resulting in higher force production compared to fast concentric contractions. Slow concentric contractions (choice C) involve controlled shortening of the muscle, leading to higher force production than fast concentric contractions.
The nurse is caring for a client diagnosed with a cerebral aneurysm who reports a severe headache. Which action should the nurse perform?
- A. Reassess the client in 15 minutes.
- B. Administer the prescribed analgesic.
- C. Inform the nurse manager.
- D. Call the physician immediately.
Correct Answer: D
Rationale: The correct answer is D. Calling the physician immediately is crucial because a severe headache in a client with a cerebral aneurysm may indicate a rupture, a life-threatening emergency. The physician needs to be notified promptly for urgent intervention. Reassessing the client in 15 minutes (Choice A) may delay necessary action. Administering an analgesic (Choice B) without knowing the underlying cause of the headache could mask symptoms and delay appropriate treatment. Informing the nurse manager (Choice C) is not the priority; direct communication with the physician for immediate medical intervention is essential in this situation.
In a patient with acromegaly, the nurse will expect to discover which assessment findings?
- A. Heavy, flattened facial features
- B. Growth retardation and a delayed onset of puberty
- C. Overgrowth of bone in the face, head, hands, and feet
- D. Increased height and weight and delayed sexual development
Correct Answer: C
Rationale: Rationale: Acromegaly is a condition caused by excessive growth hormone production, leading to overgrowth of bones in the face, head, hands, and feet. This results in characteristic features such as enlarged facial bones, hands, and feet. The correct answer is C because it aligns with the typical assessment findings in acromegaly.
Summary of other choices:
A (Heavy, flattened facial features): This is not consistent with acromegaly, as the condition is characterized by overgrowth of bone rather than flattened features.
B (Growth retardation and a delayed onset of puberty): These findings are more indicative of growth hormone deficiency rather than excess, which is seen in acromegaly.
D (Increased height and weight and delayed sexual development): While increased height and weight may occur, delayed sexual development is not a common feature of acromegaly.