Nokea
A healthcare professional assesses a client who is experiencing an acute asthma attack. Which assessment finding requires immediate intervention?
- A. Loud wheezing
- B. Increased respiratory rate
- C. Use of accessory muscles
- D. Silent chest
Correct Answer: D
Rationale: The correct answer is D: Silent chest. This finding indicates severe airway obstruction and impending respiratory failure, requiring immediate intervention to prevent respiratory arrest. Silent chest means minimal or absent breath sounds, suggesting no air movement, which is a critical emergency situation. Wheezing (A), increased respiratory rate (B), and use of accessory muscles (C) are common in asthma attacks but do not indicate as severe a condition as a silent chest. Monitoring and addressing a silent chest promptly is crucial in managing acute asthma exacerbations.
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How are pulse rate, volume, and rhythm used to identify the severity of shock and estimate the approximate reduction in blood volume?
- A. Decreased blood pressure
- B. Increased heart rate
- C. Fluid retention
- D. Muscle cramps
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A client with a new tracheostomy is being seen in the oncology clinic. What finding by the nurse best indicates that goals for the nursing diagnosis Impaired Self-Esteem are being met?
- A. The client demonstrates a good understanding of stoma care.
- B. The client has joined a book club that meets at the library.
- C. Family members take turns assisting with stoma care.
- D. Skin around the stoma is intact without signs of infection.
Correct Answer: B
Rationale: The correct answer is B because joining a book club indicates the client is engaging in social activities and pursuing interests, which can boost self-esteem. Choice A focuses on physical care, not self-esteem. Choice C involves family support, not necessarily self-esteem. Choice D only addresses physical health, not emotional well-being. Overall, engaging in social activities promotes self-worth and a sense of belonging, aligning with the goal of improving self-esteem.
According to the World Health Organization, identify the specific goals of palliative care (select all that apply).
- A. Regard dying as a normal process.
- B. Minimize the financial burden on the family.
- C. Provide relief from symptoms
- D. including pain.
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A client with chronic obstructive pulmonary disease (COPD) appears thin and disheveled. Which question should the nurse ask first?
- A. Do you have a strong support system?
- B. What do you understand about your disease?
- C. Do you experience shortness of breath with basic activities?
- D. What medications are you prescribed to take each day?
Correct Answer: C
Rationale: The correct question to ask first is C: "Do you experience shortness of breath with basic activities?" This is because shortness of breath is a common and concerning symptom in COPD patients that can greatly impact their quality of life and indicate disease progression. By addressing this symptom first, the nurse can assess the severity of the client's condition and determine the immediate need for intervention or treatment. Asking about support system (A) is important but not as urgent as addressing the primary symptom. Inquiring about the client's understanding of the disease (B) and medications (D) is also important but should come after addressing the immediate symptom of shortness of breath.
A client learns about pursed-lip breathing. Which statement by the client indicates teaching has been effective?
- A. I will breathe in quickly through my mouth and out through my nose.
- B. I will breathe in slowly through my nose and out through pursed lips.
- C. I will hold my breath for 10 seconds before exhaling.
- D. I will breathe in and out through pursed lips.
Correct Answer: B
Rationale: The correct answer is B because pursed-lip breathing involves inhaling slowly through the nose and exhaling slowly through pursed lips, which helps improve lung function and relaxes the client. Choice A is incorrect because breathing in quickly through the mouth is not part of pursed-lip breathing technique. Choice C is incorrect as holding breath before exhaling is not recommended in pursed-lip breathing. Choice D is partially correct but lacks the emphasis on inhaling slowly through the nose. Therefore, the most effective statement indicating correct teaching is choice B.