Nokea
Mary is diagnosed with a brain tumor and is unable to speak. Where is the tumor probably located?
- A. Occipital lobe.
- B. Cerebellum.
- C. Frontal lobe.
- D. Parietal lobe.
Correct Answer: C
Rationale: The frontal lobe controls speech and language functions.
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Which test involves providing quick responses to words like 'mother...', 'work...', et ?
- A. Minnesota Multiphasic Personality Inventory
- B. Word Association Test
- C. Rorschach Test
- D. Beck Depression Inventory
Correct Answer: B
Rationale: The Word Association Test requires clients to quickly respond to words, revealing unconscious thoughts and emotions through their responses.
What condition can develop if Mr. Taylor’s chest tube is accidentally pulled out?
- A. Tension pneumothorax
- B. Open pneumothorax
- C. Hemopneumothorax
- D. Paradoxic respirations
Correct Answer: B
Rationale: An open pneumothorax occurs when air enters the pleural space through an external opening.
The healthcare provider is caring for a postoperative client who has a chest tube connected to suction and a water seal drainage system. Which of the following indicates to the healthcare provider that the chest tube is functioning properly?
- A. Fluctuation of the fluid level within the water seal chamber
- B. Absence of fluid in the drainage tubing
- C. Continuous bubbling within the water seal chamber
- D. Equal amounts of fluid drainage in each collection chamber
Correct Answer: A
Rationale: The correct answer is A: Fluctuation of the fluid level within the water seal chamber. This indicates proper chest tube function as it shows that the system is maintaining the desired pressure and allowing for adequate drainage without obstruction. When the patient breathes in and out, the fluid level fluctuates due to changes in intrathoracic pressure.
Explanation of other choices:
B: Absence of fluid in the drainage tubing - This would indicate a problem with drainage, possibly due to a blockage in the tubing.
C: Continuous bubbling within the water seal chamber - This would suggest an air leak in the system, which is not ideal as it can lead to lung collapse.
D: Equal amounts of fluid drainage in each collection chamber - While equal drainage is good, it does not specifically indicate proper chest tube function like the fluctuation of the fluid level does.
A client with a chest tube connected to a closed drainage system needs to be transported to the x-ray department. Which of the following actions should the nurse take?
- A. Clamp the chest tube prior to transferring the client to a wheelchair.
- B. Disconnect the chest tube from the drainage system during transport.
- C. Keep the drainage system below the level of the client's chest at all times.
- D. Empty the collection chamber prior to transport.
Correct Answer: C
Rationale: The correct answer is C: Keep the drainage system below the level of the client's chest at all times. This is important to prevent backflow of air or fluid into the client's chest, which can lead to complications such as a pneumothorax or hemothorax. Gravity ensures that the drainage system functions properly and prevents any potential harm to the client.
A: Clamping the chest tube prior to transferring the client is incorrect as it can cause a dangerous buildup of pressure in the chest.
B: Disconnecting the chest tube from the drainage system can also lead to complications and disrupt the drainage process.
D: Emptying the collection chamber is important but not the priority during transport; keeping the drainage system below the chest level is crucial for the client's safety.
Which of the following would be appropriate to delegate to the nursing assistant?
- A. Assist the child to remove outer clothing
- B. Advise the parent to use acetaminophen instead of aspirin
- C. Explain the need for cool fluids
- D. Prepare and administer a tepid bath
Correct Answer: A
Rationale: Removing outer clothing is a simple task that does not require clinical judgment.