Nokea
The client is diagnosed with a pneumothorax. Which finding is most expected on auscultation?
- A. Bilateral crackles
- B. Diminished breath sounds on the affected side
- C. Wheezing throughout lung fields
- D. Rhonchi in the lower lobes
Correct Answer: B
Rationale: A pneumothorax causes collapsed lung tissue, resulting in diminished or absent breath sounds on the affected side. Crackles, wheezing, and rhonchi are not typical.
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A 55-year-old client is admitted with a diagnosis of renal calculi. He presented with severe right flank pain, nausea, and vomiting. The most important nursing action for him at this time is:
- A. Intake and output measurement
- B. Daily weights
- C. Straining of all urine
- D. Administration of O2 therapy
Correct Answer: C
Rationale: Straining urine provides for assessment of calculi and evaluation of calculi descent through ureters and urethra.
A 10-year-old client with a pin in the right femur is immobilized in traction. He is exhibiting behavioral changes including restlessness, difficulty with problem solving, inability to concentrate on activities, and monotony. Which of the following nursing implementations would be most effective in helping him cope with immobility?
- A. Providing him with books, challenging puzzles, and games as diversionary activities
- B. Allowing him to do as much for himself as he is able, including learning to do pin-site care under supervision
- C. Having a volunteer come in to sit with the client and to read him stories
- D. Stimulating rest and relaxation by gentle rubbing with lotion and changing the client's position frequently
Correct Answer: B
Rationale: Self-care is usually well received by the child, and it is one of the most useful interventions to help the child cope with immobility, providing a sense of control.
The nurse would expect to include which of the following when planning the management of the client with Lyme disease?
- A. Complete bed rest for 6-8 weeks
- B. Tetracycline treatment
- C. IV amphotericin B
- D. High-protein diet with limited fluids
Correct Answer: B
Rationale: The client is not placed on complete bed rest for 6 weeks. Tetracycline is the treatment of choice for children with Lyme disease who are over the age of 9. IV amphotericin B is the treatment for histoplasmosis. The client is not restricted to a high-protein diet with limited fluids.
The physician has diagnosed a client with cirrhosis characterized by asterixis. If the nurse assesses the client with asterixis, he can expect to find:
- A. Irregular movement of the wrist
- B. Enlargement of the breasts
- C. Dilated veins around the umbilicus
- D. Redness of the palmar surfaces
Correct Answer: A
Rationale: Asterixis, a flapping tremor of the wrists when extended, is a sign of hepatic encephalopathy in cirrhosis due to ammonia buildup. The other findings are unrelated to asterixis.
The client is receiving chemotherapy for breast cancer. Which instruction should the nurse include to prevent infection?
- A. Avoid crowds and people with colds.'
- B. Take your temperature twice a week.'
- C. Eat only well-cooked meats.'
- D. Use a soft toothbrush for oral care.'
Correct Answer: A
Rationale: Chemotherapy causes immunosuppression, increasing infection risk. Avoiding crowds and sick individuals reduces exposure to pathogens. The other measures are helpful but less effective at preventing infection.