In a client diagnosed with superficial mycotic infections, which of the following should the nurse closely monitor for infection?
- A. Eyes and ears
- B. Skin,hair and nails
- C. Subcutaneous tissues
- D. Mouth and teeth
Correct Answer: B
Rationale: The correct answer is B because superficial mycotic infections primarily affect the skin, hair, and nails, making these areas critical to monitor.
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In an emergency department, a healthcare provider is preparing to care for a client with multiple system trauma following a motor vehicle crash. What should be the priority focus of care?
- A. Airway protection
- B. Decreasing intracranial pressure
- C. Stabilizing cardiac arrhythmias
- D. Preventing musculoskeletal disability
Correct Answer: A
Rationale: The correct answer is A: Airway protection. The priority focus of care in a client with multiple system trauma is to ensure a patent airway to maintain oxygenation and ventilation. Without a clear airway, the client can rapidly deteriorate. Airway management takes precedence over other interventions to prevent hypoxia and respiratory failure. Decreasing intracranial pressure (B) and stabilizing cardiac arrhythmias (C) are important but secondary to ensuring adequate oxygenation. Preventing musculoskeletal disability (D) is not the immediate concern in this critical situation.
A patient in heroin withdrawal comes to the nurse's station demanding a narcotic saying he or she is going to die from the withdrawal. The patient received detox medication 30 minutes ago. What is the best response?
- A. Call a rapid response before the patient has a seizure.
- B. Tell the patient he or she is not going to die from opioid withdrawal and that you will see if he or she has any PRN medications available.
- C. Tell the patient to speak with the practitioner in the morning.
- D. Tell the patient that you will call the practitioner now to see if the practitioner will order a narcotic.
Correct Answer: B
Rationale: Reassurance and checking for available PRN medications address both the patient's anxiety and potential need for additional symptom management.
What findings indicate tension pneumothorax causing mediastinal shift?
- A. Diminished breath sounds on left side; trachea deviated to right; decreasing blood pressure, increasing pulse rate
- B. Rapid, shallow respirations; trachea deviated to left; slow pulse; collapsed neck veins
- C. Dyspnea; hyperresonance on right; widened pulse pressure; rapid, bounding pulse
- D. Chest pain; cyanosis; collapsed neck veins; decreasing pulse rate
Correct Answer: A
Rationale: Tension pneumothorax causes unilateral lung collapse, mediastinal shift, hypotension, and tachycardia.
Which statement by a patient demonstrates an accurate understanding about herbal supplements?
- A. Herbs may interact with prescribed medications but not other herbs.
- B. Most herbs have been tested and found to be safe and therapeutic.
- C. The Food and Drug Administration regulates herbs and allows advertising.
- D. There is no standardization among the manufacturers of herbs in this country.
Correct Answer: D
Rationale: Herbal supplements lack standardization and regulation in the U.S.
Which nutritional instruction is important for stress-prone clients?
- A. Provide individual and group counseling
- B. Provide books on psychobiologic illness
- C. Provide entertainment regularly
- D. Provide family counseling
Correct Answer: A
Rationale: Individual and group counseling can help clients develop healthy coping mechanisms and emotional support systems.