Nokea
If the client develops a pneumothorax, which of the following assessment findings should the nurse expect?
- A. Stridor
- B. Pain on inhalation chest pain that worsens when you breathe or pleuritic pain
- C. Friction rub
- D. Bradycardia
Correct Answer: B
Rationale: The correct answer is B: Pain on inhalation chest pain that worsens when you breathe or pleuritic pain. A pneumothorax is the presence of air in the pleural space, causing lung collapse. When air enters this space, it creates pressure, leading to sharp chest pain that worsens with breathing (pleuritic pain). This occurs because the air-filled space prevents the lungs from expanding fully during inhalation, causing discomfort. Stridor (choice A) is a high-pitched sound indicating upper airway obstruction, not typically associated with a pneumothorax. Friction rub (choice C) indicates inflammation of the pleura, not specific to a pneumothorax. Bradycardia (choice D) is unlikely in pneumothorax, as it is more commonly associated with conditions affecting the heart rate.
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Which of the following instructions by the nurse is appropriate?
- A. Tighten your muscles before relaxing them when using muscle relaxation techniques
- B. Avoid deep breathing exercises, as they can increase stress.
- C. Focus on multiple thoughts at once to distract yourself from stress.
- D. Keep your emotions bottled up to maintain control over stress.
Correct Answer: A
Rationale: The correct answer is A because tightening muscles before relaxing them helps to enhance the effectiveness of muscle relaxation techniques by creating a greater sense of contrast between tension and relaxation. This sequence promotes deeper relaxation and can help reduce stress more effectively. Choice B is incorrect as deep breathing exercises are commonly used to reduce stress and promote relaxation. Choice C is incorrect as focusing on multiple thoughts at once can increase stress and overwhelm the individual. Choice D is incorrect as bottling up emotions can lead to increased stress and negatively impact mental health.
Which action should the nurse include in the plan?
- A. Minimize noise in the newborn's environment.
- B. Swaddle the newborn loosely to allow free movement.
- C. Position the newborn supine with legs extended.
- D. Encourage frequent handling and stimulation.
Correct Answer: A
Rationale: The correct answer is A because minimizing noise in the newborn's environment is crucial for promoting rest and reducing stress. Newborns are highly sensitive to loud noises, which can disrupt their sleep and affect their overall well-being. By creating a quiet environment, the nurse helps the newborn to feel secure and comfortable, promoting better sleep and overall development.
Choice B is incorrect because swaddling the newborn loosely may pose a suffocation risk and restrict movement, which is not recommended. Choice C is incorrect as positioning the newborn supine with legs extended may increase the risk of sudden infant death syndrome (SIDS). Choice D is also incorrect as encouraging frequent handling and stimulation can overwhelm the newborn's developing nervous system and lead to increased stress.
Which of the following action should the nurse take?
- A. Determine if the AP has the skills to perform the test.
- B. Help the AP performed the blood glucose test
- C. Assign the AP to ask the client is taking his diabetic medication today
- D. Have AP check the medical record for prior blood glucose test results
Correct Answer: A
Rationale: The correct answer is A because the nurse should first assess if the AP has the necessary skills to perform the blood glucose test. This step is crucial to ensure patient safety and accurate test results. Helping the AP perform the test (B) without assessing their skills can lead to errors. Assigning the AP to ask about medication (C) is not directly related to the task at hand. Having the AP check records (D) is important but should come after confirming their skills. The other choices are not relevant to the immediate situation.
Which of the following information should the nurse include?
- A. Return in two weeks for a follow up MRI - MRI should be avoided
- B. Expect to have a rapid pulse rate for the first few weeks?
- C. Resume tub baths and swimming after 24hr
- D. Wear loose fitting clothing
Correct Answer: D
Rationale: The correct answer, D, "Wear loose fitting clothing," is important post-surgery to prevent constriction on the surgical site and promote healing. Tight clothing can lead to increased pain and delayed recovery. Choice A is incorrect as MRI should be avoided post-surgery due to potential interference with healing. Choice B is incorrect as a rapid pulse rate is not a typical expectation post-surgery. Choice C is incorrect as tub baths and swimming should be avoided to prevent infection.
Which of the following actions should the nurse plan to take?
- A. Apply a cold compress to the site.
- B. Elevate the affected arm above heart level.
- C. Place a warm, moist compress on the site.
- D. Massage the area to reduce inflammation.
Correct Answer: B
Rationale: The correct answer is B: Elevate the affected arm above heart level. Elevating the affected arm helps reduce swelling and promote circulation, aiding in the healing process. By elevating the arm above heart level, the nurse can assist in reducing inflammation and preventing further complications. Applying a cold compress (choice A) can be helpful for acute injuries, but it may not be the most appropriate initial action. Placing a warm, moist compress (choice C) can potentially worsen swelling in this case. Massaging the area (choice D) could aggravate the injury and increase inflammation.