Nokea
The nurse has been assigned to these clients in the emergency room. Which client would the nurse go check first?
- A. Viral pneumonia with atelectasis.
- B. Spontaneous pneumothorax with a respiratory rate of 38.
- C. Tension pneumothorax with slight tracheal deviation to the right.
- D. Acute asthma with episodes of bronchospasm.
Correct Answer: C
Rationale: Tension pneumothorax is a life-threatening condition requiring immediate attention.
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Following a bone marrow transplant, the patient has an increased risk for
- A. Bleeding.
- B. Infection.
- C. Clot formation.
- D. Nausea and vomiting.
Correct Answer: B
Rationale: Immunosuppression increases the risk of infection post-transplant.
One risk factor that increases a woman's chances of getting breast cancer includes:
- A. Family history
- B. Young age at first birth
- C. Multiple births
- D. Underwire bras
Correct Answer: A
Rationale: Family history is a significant risk factor for breast cancer, indicating genetic predisposition.
What best evaluates Mrs. West’s situation with wound separation and purulent drainage?
- A. This response is consistent with the inflammatory process
- B. Some drainage is to be expected from a surgical incision
- C. This response indicates a break in sterile technique has occurred
- D. This wound is healing by first intention
Correct Answer: A
Rationale: Inflammatory signs suggest infection, requiring further evaluation and treatment.
An 88-year-old woman is brought to the health clinic for the first time by her 64-year-old daughter. During the initial comprehensive nursing assessment of the patient, what should the nurse do?
- A. Ask the daughter whether the patient has any urgent needs or problems.
- B. Interview the patient and daughter together so that pertinent information can be confirmed.
- C. Obtain a health history using a functional health pattern and assess activities of daily living (ADLs) and mental status.
- D. Refer the patient for an interdisciplinary comprehensive geriatric assessment because at her age she will have multiple needs.
Correct Answer: C
Rationale: Assessing ADLs, mental status, and obtaining a thorough health history ensures comprehensive understanding of the patient's needs.
Which type of stress helps individuals pursue goals and solve problems?
- A. Energy stress
- B. Active stress
- C. Eustress
- D. Distress
Correct Answer: C
Rationale: Eustress is positive stress that motivates individuals to achieve goals, learn new skills, and manage crises effectively.