Nokea
The male client has had a radial neck dissection for cancer of the larynx. Which action by the client indicates a disturbance in body image?
- A. The client requests a consultation by the speech therapist.
- B. The client has a towel placed over the mirror.
- C. The client is attempting to shave himself.
- D. The client practices neck and shoulder exercises.
Correct Answer: B
Rationale: Placing a towel over the mirror (choice 2) suggests the client is avoiding looking at their altered appearance due to the radical neck dissection, indicating a disturbance in body image. This surgery often results in visible changes, such as scarring or a tracheostomy, which can impact self-perception. Requesting a speech therapist (choice 1) focuses on communication, attempting to shave (choice 3) shows engagement in self-care, and practicing exercises (choice 4) indicates recovery efforts, none of which directly reflect body image issues.
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The client has been diagnosed with chronic sinusitis. Which sign/symptom alerts the nurse to a potentially life-threatening complication?
- A. Muscle weakness.
- B. Purulent sputum.
- C. Nuchal rigidity.
- D. Intermittent loss of muscle control.
Correct Answer: C
Rationale: Nuchal rigidity (C) suggests meningitis, a life-threatening sinusitis complication. Muscle weakness (A) and loss of control (D) are unrelated, and purulent sputum (B) is more typical of respiratory infections.
The nurse is caring for the client diagnosed with COPD. Which outcome requires a revision in the plan of care?
- A. The client has no signs of respiratory distress.
- B. The client shows an improved respiratory pattern.
- C. The client demonstrates intolerance to activity.
- D. The client participates in establishing goals.
Correct Answer: C
Rationale: Activity intolerance (C) indicates poor COPD control, requiring plan revision. No distress (A), improved breathing (B), and goal participation (D) are positive outcomes.
The client diagnosed with tuberculosis has been treated with antitubercular medications for six (6) weeks. Which data would indicate the medications have been effective?
- A. A decrease in the white blood cells in the sputum.
- B. The client's symptoms are improving.
- C. No change in the chest X-ray.
- D. The skin test is now negative.
Correct Answer: B
Rationale: Improved symptoms (B) after six weeks of TB treatment (e.g., reduced cough, fever) indicate medication efficacy. WBCs in sputum (A) are not a standard measure. Chest X-ray changes (C) lag behind clinical improvement. The skin test (D) remains positive post-exposure, regardless of treatment.
The client is diagnosed with mild intermittent asthma. Which medication should the nurse discuss with the client?
- A. Daily inhaled corticosteroids.
- B. Use of a 'rescue inhaler.'
- C. Use of systemic steroids.
- D. Leukotriene agonists.
Correct Answer: B
Rationale: Mild intermittent asthma requires a rescue inhaler (B) (e.g., albuterol) for PRN use. Daily corticosteroids (A), systemic steroids (C), and leukotrienes (D) are for persistent asthma.
Where did the client's embolism most likely originate?
- A. The deep veins of the legs
- B. The pulmonary artery
- C. The superior vena cava
- D. The carotid artery
Correct Answer: A
Rationale: Pulmonary emboli most commonly originate from deep vein thrombosis in the legs, where clots dislodge and travel to the lungs.