Nokea
Select the sound that is heard with percussion with its description.
- A. Tympany: A hollow sound
- B. Dullness: A thud like sound
- C. Dullness: A hollow sound
- D. Resonance: A booming sound
Correct Answer: A,B,D
Rationale: Tympany is a hollow sound (e.g., over air-filled structures like the stomach), dullness is a thud-like sound (e.g., over solid organs like the liver), and resonance is a booming sound (e.g., over lung tissue). Option C is incorrect because dullness is not a hollow sound.
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The nurse is assessing a teenage girl. According to the fi gure below, the nurse should note that the girl has:
- A. Kyphosis.
- B. Arthritis.
- C. Developmental dysplasia of the hip.
- D. Scoliosis.
Correct Answer: D
Rationale: The teenage girl has scoliosis, the lateral deviation of the spine. Kyphosis is noted by a forward curvature of the shoulders. Arthritis is diagnosed by radiographs. Hip dysplasia is noted in older children by pain, but is usually diagnosed before the child walks by noting excessive gluteal folds and limited hip abduction.
A nulligravid client calls the clinic and tells the nurse that she forgot to take her oral contraceptive in the morning. Which of the following should the nurse instruct the client to do?
- A. Take the medication immediately.
- B. Restart the medication in the morning.
- C. Use another form of contraception for 2 weeks.
- D. Take two pills tonight before bedtime.
Correct Answer: A
Rationale: Taking the missed pill immediately maintains hormonal levels, minimizing the risk of ovulation. Additional contraception may be needed if more doses are missed.
A client has been receiving radiation therapy for 3 weeks to treat his cancer. He is complaining of fatigue. Which of the following should be considered while the nurse plans interventions to help the client with the fatigue?
- A. Fatigue is a temporary problem that requires no active intervention
- B. The client should be closely examined to determine the cause of fatigue
- C. Fatigue indicates that the client's cancer is not under control
- D. The client should be encouraged to maintain activity to combat the fatigue
Correct Answer: B
Rationale: Fatigue during radiation therapy may have multiple causes (e.g., anemia, dehydration), requiring thorough assessment to guide interventions. It is not always temporary, not necessarily indicative of cancer progression, and activity should be balanced, not forced.
The nurse caring for a client prescribed clozapine reviews the client's laboratory studies. Which laboratory study is the priority to monitor for an adverse effect associated with the use of this medication?
- A. Platelet count
- B. Cholesterol level
- C. Blood urea nitrogen
- D. White blood cell count
Correct Answer: D
Rationale: Hematological reactions can occur in the client taking clozapine, an atypical antipsychotic, and include agranulocytosis and mild leukopenia. The white blood cell count should be assessed before initiating treatment and should be monitored closely during the use of this medication. The client should also be monitored for signs indicating agranulocytosis, which may include sore throat, malaise, and fever. The remaining options are unrelated to the use of this medication.
When planning a presentation on the topic of osteoporosis to a group of middle-aged women, which of the following should the nurse plan to include in the presentation?
- A. An early symptom of osteoporosis is the dowager's hump
- B. African American and Latina women are at greater risk
- C. Loss of height is an early symptom of the disease
- D. Conventional radiographs are usually used to confirm the disease
Correct Answer: C
Rationale: Loss of height is an early symptom of osteoporosis due to vertebral compression fractures. Dowager's hump is a later sign, Caucasian and Asian women are at higher risk, and bone density scans, not radiographs, confirm diagnosis.