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The nurse is performing an otoscopic examination on a client with a suspected diagnosis of mastoiditis. Which finding should the nurse expect to note if this disorder was present?
- A. A dull red tympanic membrane
- B. A mobile tympanic membrane
- C. A transparent tympanic membrane
- D. A pearly colored tympanic membrane
Correct Answer: A
Rationale: Otoscopic examination of a client with mastoiditis reveals a red, dull, thick, and immobile tympanic membrane with or without perforation. Options 2, 3, and 4 indicate normal findings in an otoscopic examination.
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A client experiencing trigeminal neuralgia (tic douloureux) asks the nurse for a snack and something to drink. Which is the best selection the nurse should provide for the client?
- A. Hot cocoa with honey and toast
- B. Vanilla pudding and lukewarm milk
- C. Hot herbal tea with graham crackers
- D. Iced coffee and peanut butter and crackers
Correct Answer: B
Rationale: Because mild tactile stimulation of the face of clients with trigeminal neuralgia can trigger pain, the client needs to eat or drink lukewarm, nutritious foods that are soft and easy to chew. Extremes of temperature will cause trigeminal pain.
The nurse notes that a large number of clients reporting the presence of flulike symptoms are being seen in the clinic. Which recommendations should the nurse provide to these clients to minimize their risk for further illness? Select all that apply.
- A. Get plenty of rest.
- B. Increase intake of liquids.
- C. Get a flu shot immediately.
- D. Take antipyretics for fever.
- E. Consume a well-balanced diet.
Correct Answer: A,B,D,E
Rationale: Treatment for the flu includes getting rest, drinking fluids, and taking in nutritious foods and beverages. Medications such as antipyretics and analgesics may also be used for symptom management. Immunizations against influenza are a prophylactic measure and are not used to treat flu symptoms.
The nurse is preparing to administer a tuberculin skin test to a client. The nurse determines that which area is to be used for injection of the medication?
- A. Dorsal aspect of the upper arm near a mole
- B. Inner aspect of the forearm that is close to a burn scar
- C. Inner aspect of the forearm that is not heavily pigmented
- D. Dorsal aspect of the upper arm that has a small amount of hair
Correct Answer: C
Rationale: Intradermal injections are most commonly given in the inner surface of the forearm. Other sites include the dorsal area of the upper arm or the upper back beneath the scapulae. The nurse finds an area that is not heavily pigmented and is clear of hairy areas or lesions that could interfere with reading the results.
The nurse is caring for a term newborn. Which assessment finding would predispose the newborn to the occurrence of jaundice?
- A. Presence of a cephalhematoma
- B. Infant blood type of O negative
- C. Birth weight of 8 pounds 6 ounces
- D. A negative direct Coombs' test result
Correct Answer: A
Rationale: A cephalhematoma is swelling caused by bleeding into an area between the bone and its periosteum (does not cross over the suture line). Enclosed hemorrhage, such as with cephalhematoma, predisposes the newborn to jaundice by producing an increased bilirubin load as the cephalhematoma resolves (usually within 6 weeks) and is absorbed into the circulatory system. The classic Rh incompatibility situation involves an Rh-negative mother with an Rh-positive fetus/newborn. The birth weight in option 3 is within the acceptable range for a term newborn and therefore does not contribute to an increased bilirubin level. A negative direct Coombs' test result indicates that there are no maternal antibodies on fetal erythrocytes.
An echocardiogram, chest x-ray (CXR), and computed axial tomography (CAT) scan are prescribed for a client who has activity intolerance. In which order should the nurse plan to schedule the procedures to meet the needs of this client safely and effectively?
- A. CAT scan and CXR in the morning, and echocardiogram on the following morning
- B. CXR and echocardiogram together in the morning, and CAT scan in the afternoon of the same day
- C. Echocardiogram in the morning, and CXR and CAT scans together in the afternoon of the same day
- D. CXR in the morning, echocardiogram in the afternoon, and CAT scan in the morning of the following day
Correct Answer: D
Rationale: CAT scans are always performed in radiology, and CXR and echocardiograms can be done at the bedside; however, the best results usually occur when the test is performed in the related department. As long as the client is stable and transportation is provided, the nurse can schedule each procedure in its department with two procedures on the first day separated by a rest period, and the remaining procedure the next day.