Nokea
The nurse is assessing a client with suspected pulmonary edema. Which finding is most indicative?
- A. Dry cough.
- B. Crackles at lung bases.
- C. Clear breath sounds.
- D. Decreased respiratory rate.
Correct Answer: B
Rationale: Crackles at lung bases indicate fluid in the alveoli, a hallmark of pulmonary edema.
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A nurse is caring for a client with a new colostomy. Which of the following actions should the nurse include in the teaching plan to prevent skin breakdown around the stoma?
- A. Apply a skin barrier around the stoma
- B. Use soap to clean the stoma site
- C. Leave the pouch off for 2 hours daily
- D. Apply petroleum jelly to the stoma
Correct Answer: A
Rationale: A skin barrier protects the peristomal skin from irritation caused by stool. Soap can irritate the skin, leaving the pouch off risks exposure, and petroleum jelly is not recommended.
The nurse assesses a client scheduled for a thyroidectomy for psychosocial problems that may cause preoperative anxiety. Considering the nature of the surgery which client fear is a realistic source of anxiety?
- A. Sexual dysfunction and infertility
- B. Imposed dietary restrictions after discharge
- C. Developing gynecomastia and hirsutism postoperatively
- D. Changes in body image secondary to the location of the incision
Correct Answer: D
Rationale: Because the incision is in the neck area, the client may be fearful of having a large scar postoperatively. Sexual dysfunction and infertility could possibly occur if the entire thyroid gland is removed, and the client is not placed on thyroid replacement medications. The client will not have specific dietary restrictions after discharge. Having all or part of the thyroid gland removed will not cause gynecomastia or hirsutism.
A client has received a dose of dimenhydrinate. The nurse determines that the medication is effective when the client obtains relief of which problem?
- A. Chills
- B. Headache
- C. Ringing in the ears
- D. Nausea and vomiting
Correct Answer: D
Rationale: Dimenhydrinate is used to treat and prevent the symptoms of dizziness, vertigo, and nausea and vomiting that accompany motion sickness. None of the other options are associated with the described symptoms.
A client is in the advanced stages of osteoarthritis. Which of the following best describes the pain that occurs in the advanced stage of the disease?
- A. Pain occurs with minimal activity.
- B. Crepitation develops and intensifies pain.
- C. Joints are symmetrically affected by pain.
- D. Fatigue accompanies pain.
Correct Answer: A
Rationale: In advanced osteoarthritis, pain occurs with minimal activity due to significant joint damage and inflammation.
A 13-year-old male was kidnapped and held for ransom by two criminals. His parents asked to have him admitted to the adolescent psychiatric unit. He is sleep-deprived, filthy, alternating between sobbing and making threats to kill his captors, and then asks to go to sleep. What is the best initial plan for this client?
- A. Encourage him to talk with the Federal Bureau of Investigation (FBI) about the crime details.
- B. Develop trust and allow him to talk about his memories and feelings.
- C. Help him and his parents prepare for the future trial.
- D. Discourage him from making threats toward his captors.
Correct Answer: B
Rationale: Building trust and allowing the client to express feelings addresses immediate emotional needs and trauma, prioritizing mental health support.