Nokea
The chest tube drainage system has continuous bubbling in the water seal chamber. When the nurse clamps different areas of the tube to find out where the bubbling stops, he is checking for:
- A. An air leak
- B. The suction being too high
- C. The suction being too low
- D. A tension pneumothorax
Correct Answer: A
Rationale: Continuous bubbling in the water seal chamber indicates an air leak, either from the lung or the system. Clamping helps locate the source of the leak.
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To decrease the likelihood of seizures and visual hallucinations in a client with alcohol withdrawal, the nurse should:
- A. Keep the room darkened by pulling the curtains
- B. Keep the light over the bed on at all times
- C. Keep the room quiet and dim the lights
- D. Keep the television or radio turned on
Correct Answer: C
Rationale: A quiet, dimly lit room reduces sensory stimulation, decreasing the risk of seizures and hallucinations during alcohol withdrawal.
The chart of a client with schizophrenia states that the client has echolalia. The nurse can expect the client to:
- A. Speak using words that rhyme
- B. Repeat words or phrases used by others
- C. Include irrelevant details in conversation
- D. Make up new words with new meanings
Correct Answer: B
Rationale: Echolalia in schizophrenia involves repeating words or phrases spoken by others, reflecting impaired communication processing.
Which symptom is not associated with glaucoma?
- A. Veil-like loss of vision
- B. Foggy loss of vision
- C. Seeing halos around lights
- D. Complaints of eye pain
Correct Answer: A
Rationale: Veil-like loss of vision is not typical of glaucoma; foggy vision, halos, and eye pain are common symptoms.
Which selection would provide the most calcium for the client who is 4 months pregnant?
- A. A granola bar
- B. A bran muffin
- C. A cup of yogurt
- D. A glass of fruit juice
Correct Answer: C
Rationale: Yogurt is a rich source of calcium, essential for fetal bone development during pregnancy.
A client who is to undergo electroconvulsive therapy for severe depression is quite anxious about the treatment and asks the nurse what to expect after treatment. Which of the following information should the nurse include? Select all that apply.
- A. The client will experience confusion for a short time.
- B. Headache and muscle soreness are common.
- C. Some degree of memory loss, usually transient, may occur.
- D. Possible urinary incontinence may occur for 12 hours.
- E. The client may experience hallucinations for 2 to 3 weeks.
Correct Answer: A,B,C
Rationale: ECT causes short-term confusion (A), headache/muscle soreness (B), and transient memory loss (C). Incontinence (D) and prolonged hallucinations (E) are not typical.