Nokea
Percussion is a physical assessment technique that is used to identify which findings?
- A. Fluid in body cavities
- B. Borders of body organs
- C. Consistency of body organs
- D. Mobility of organs and other structures
- E. Resilience and resistance of tissue and organs
- F. Location, size, and density of an underlying structure
Correct Answer: A,B,C,F
Rationale: Percussion involves tapping the body with the fingertips to evaluate the size, borders, and consistency of body organs and assess for fluid in body cavities. Through percussion, the location, size, and density of an underlying structure can be determined. Through palpation, assessment is done via the sense of touch. Measurements of specific physical signs, including resistance, resilience, roughness, texture, and mobility, can be made through palpation.
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A healthcare professional is preparing to insert an indwelling catheter in a female client. Which of the following positions of the client is most appropriate for this procedure?
- A. Lithotomy position
- B. Prone position
- C. Dorsal recumbent position
- D. High Fowler's position
Correct Answer: C
Rationale: When preparing to insert an indwelling catheter for a female client, the most appropriate position is the dorsal recumbent position. In this position, the client lies on their back with knees bent. This position allows for easy access to the urethral area for catheter insertion. The lithotomy position, with legs elevated and spread apart, is more invasive and typically used for gynecological exams. The prone position, lying face down, is not suitable for catheter insertion. High Fowler's position, sitting upright at a 90-degree angle, is not ideal for catheter insertion as it does not provide proper access to the perineal area.
The nurse should tell the client to avoid which item while taking phenelzine sulfate?
- A. Blueberries
- B. Vasodilators
- C. Aged cheeses
- D. Digitalis preparations
Correct Answer: C
Rationale: Phenelzine sulfate is in the monoamine oxidase inhibitor (MAOI) class of antidepressant medications. An individual taking an MAOI must avoid aged cheeses, alcoholic beverages, avocados, bananas, and caffeine drinks. There are also other food items to avoid, including chocolate, meat tenderizers, pickled herring, raisins, sour cream, yogurt, and soy sauce. Medications that should be avoided include amphetamines, antiasthmatics, and certain antidepressants. The client should also avoid vasoconstrictors because their concurrent use can cause hypertensive crisis.
Which of the following statements best describes compartment syndrome?
- A. An injury causes pain and tingling that starts in the buttock and travels down the leg.
- B. An injury causes swelling within muscle tissue that leads to anoxia of nerves and muscles.
- C. An injury causes permanent flexion of the interphalangeal joint, resulting in deformity.
- D. An injury causes pain and swelling of the median plantar nerve.
Correct Answer: B
Rationale: Compartment syndrome is characterized by swelling and increased pressure within a muscle compartment, leading to decreased blood flow and oxygen supply to nerves and muscles. This can result from various causes, such as trauma or the application of a cast after a fracture. If left untreated, compartment syndrome can lead to tissue necrosis. Choice A is incorrect as pain and tingling starting in the buttock and traveling down the leg are not specific features of compartment syndrome. Choice C is incorrect as permanent flexion of the interphalangeal joint is unrelated to compartment syndrome. Choice D is incorrect as pain and swelling of the median plantar nerve do not describe compartment syndrome.
A nurse is caring for an 83-year-old man who has had swallowing difficulties. All of the following interventions are appropriate for this client EXCEPT:
- A. Keep the client in an upright position at all times
- B. Auscultate lung sounds every shift and after feedings
- C. Maintain suction equipment at the client's bedside
- D. Instruct the client about how to perform swallowing exercises
Correct Answer: A
Rationale: When caring for a client with swallowing difficulties, it is crucial to prevent aspiration of food into the lungs. Appropriate interventions include auscultating lung sounds every shift and after feedings to assess for any changes in breathing patterns, maintaining suction equipment at the client's bedside in case of difficulties, and providing instruction on swallowing exercises. Keeping the client in an upright position at all times is not necessary and may not always be feasible or comfortable for the client. This rigid requirement is not part of the standard care protocol for managing swallowing difficulties.
A client has started sweating profusely due to intense heat. His overall luid volume is low and he has developed electrolyte imbalance. This client is most likely suffering from:
- A. Malignant hyperthermia
- B. Heat exhaustion
- C. Heat stroke
- D. Heat cramps
Correct Answer: B
Rationale: Heat exhaustion occurs when a person has enough diaphoresis that he becomes dehydrated. Intense sweating can cause both luid and electrolyte imbalances. Untreated heat exhaustion canlead to heat stroke, which results in organ damage, loss of consciousness, or death.