Nokea
The following are warning signs of cancer. Which one is not?
- A. Change In bladder and bowel habits
- B. Weight gain
- C. Indigestion or difficulty in swallowing
- D. Nagging cough or hoarseness
Correct Answer: B
Rationale: Weight gain is not typically considered a warning sign of cancer. In fact, unexplained weight loss is more commonly associated with certain types of cancer. The other options all relate to symptoms that could potentially be warning signs of cancer and are worth discussing with a healthcare professional for further evaluation.
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An adult suffered a diving accident and is being brought in by an ambulance intubated and on backboard with a cervical collar. What is the first action the nurse would take on arrival in the hospital?
- A. Take the client vital signs
- B. Insert a large bore IV line
- C. Check the lungs for equal breath sounds bilaterally
- D. Perform a neurologic check using the Glasgow scale
Correct Answer: B
Rationale: The first action the nurse should take upon the arrival of the adult who suffered a diving accident and is intubated and on a backboard with a cervical collar is to insert a large bore IV line. This is a priority because the person may require urgent fluid resuscitation or medication administration, and having IV access is crucial for immediate intervention in trauma cases. After establishing IV access, other assessments such as vital signs, lung sounds, and neurological checks can follow.
The MOST common type of cerebral palsy is
- A. ataxic cerebral palsy
- B. spastic cerebral palsy
- C. dystonic cerebral palsy
- D. dyskinetic cerebral palsy
Correct Answer: B
Rationale: Spastic cerebral palsy is the most common type.
A patient's chest x-ray examination indicates fluid in both lung bases. Which of the ff. signs or symptoms present during the nurse's assessment most reflects these x-ray examination findings?
- A. Fatigue
- B. Peripheral edema
- C. Bilateral crackles
- D. Jugular vein distention
Correct Answer: C
Rationale: The presence of fluid in both lung bases, as indicated by the chest x-ray examination, suggests the possibility of pulmonary congestion or fluid accumulation in the lungs. Bilateral crackles, also known as rales, are a common clinical finding associated with pulmonary edema. Crackles are discontinuous, brief, popping sounds heard on auscultation of the lungs. These adventitious breath sounds occur when air passes through fluid in the small airways or alveoli. Therefore, the presence of bilateral crackles during the nurse's assessment would most reflect the x-ray examination findings of fluid in both lung bases. Fatigue, peripheral edema, and jugular vein distention may also be present in conditions involving fluid overload, such as heart failure, but bilateral crackles specifically point to the presence of fluid in the lungs.
Mr. Mariano was on his way home from a party. Apparently, he got drunk and lost his balance and suffered a vehicular accident. Upon arrival at the hospital, the nurse noticed that his only injury is an open fracture of the left humerus. Which assessment finding by the nurse is critical?
- A. status of client's tetanus immunization
- B. current blood alcohol level
- C. support systems available at home to assist with care
- D. last time client voided
Correct Answer: A
Rationale: In this situation where Mr. Mariano has an open fracture of the left humerus, the nurse's critical assessment finding should be the status of the client's tetanus immunization. An open fracture poses a risk of infection, and tetanus is a concern due to the potential exposure to bacteria from the environment causing tetanus. Tetanus is a serious bacterial infection that affects the nervous system and can be fatal if not treated promptly. Knowing the client's tetanus immunization status will help determine the need for a tetanus booster to prevent this potentially life-threatening infection. Blood alcohol level, support systems at home, and voiding time are important assessments as well, but in the case of an open fracture, the priority is to assess the risk of tetanus infection.
Under which of the ff situations should a nurse notify the physician when caring for a client with lymphangitis? Choose all that apply
- A. Affected area appears to enlarge
- B. Red streaks extend up the arm or leg
- C. Additional lymph nodes become
- D. Liver and spleen become enlarged
Correct Answer: A
Rationale: A nurse should notify the physician when caring for a client with lymphangitis under the following situations: