Nokea
A client with a new tracheostomy is being seen in the oncology clinic. What finding by the nurse best indicates that goals for the client's decrease in self-esteem are being met?
- A. The client demonstrates good understanding of stoma care.
- B. The client has joined a book club that meets at the library.
- C. Family members take turns assisting with stoma care.
- D. Skin around the stoma is intact without signs of infection.
Correct Answer: B
Rationale: The correct answer is B because joining a book club shows an improvement in social engagement and participation, indicating an increase in self-esteem. This choice demonstrates the client's interest in activities outside of their healthcare needs, promoting a sense of normalcy and connection. In contrast, options A, C, and D focus solely on stoma care and physical aspects, not directly related to self-esteem. Understanding stoma care (A) is important but does not address self-esteem directly. Family assistance (C) is supportive but does not necessarily indicate an improvement in the client's self-esteem. Skin integrity (D) is essential for physical health but does not reflect self-esteem.
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A nurse assesses a client after a thoracentesis. Which assessment finding warrants immediate action?
- A. The client rates pain as a 5/10 at the site of the procedure.
- B. A small amount of drainage from the site is noted.
- C. Pulse oximetry is 93% on 2 liters of oxygen.
- D. The trachea is deviated toward the opposite side of the neck.
Correct Answer: D
Rationale: The correct answer is D because tracheal deviation indicates a potential pneumothorax, a life-threatening complication of thoracentesis. Trachea should be midline. A, B, and C are incorrect because mild pain, small drainage, and slightly decreased oxygen saturation are expected findings post-thoracentesis and do not necessitate immediate action.
Pain with chronic stable angina is due to:
- A. Rubbing of epicardium against the pericardial sac.
- B. Insufficient blood flow due to narrowing of the coronary arteries
- C. Irritation of cardiac nerve endings in the chest wall
- D. Dilation of the coronary arteries to increase blood flow
Correct Answer: B
Rationale: The correct answer is B because chronic stable angina is caused by insufficient blood flow due to narrowing of the coronary arteries, leading to inadequate oxygen supply to the heart muscle during exertion. This results in chest pain.
A is incorrect as there is no rubbing of epicardium against the pericardial sac in chronic stable angina.
C is incorrect as the pain is not due to irritation of cardiac nerve endings in the chest wall.
D is incorrect as dilation of the coronary arteries does not cause pain in chronic stable angina; it is actually a compensatory mechanism to increase blood flow in response to decreased oxygen supply.
In general, when looking at acid-base balance, how does the body compensate with metabolic acidosis?
- A. Lungs ""blow off"" CO2 to raise pH
- B. Lungs retain CO2 to lower pH
- C. Kidneys retain more HCO3 to raise the pH
- D. Kidneys excrete more HCO3 to lower pH
Correct Answer: A
Rationale: The correct answer is A. In metabolic acidosis, the lungs compensate by increasing respiratory rate and depth ('blowing off' CO2) to reduce acidity and raise pH. B is incorrect because retaining CO2 would worsen acidosis. C is partially true long-term but slower acting than pulmonary compensation. D is incorrect because excreting bicarbonate lowers pH further.
A nurse performs an admission assessment on a client with a diagnosis of tuberculosis. The nurse reviews the results of which diagnostic test that will confirm this diagnosis?
- A. Bronchoscopy.
- B. Sputum culture.
- C. Chest x-ray.
- D. Tuberculin skin test.
Correct Answer: B
Rationale: The correct answer is B: Sputum culture. This test confirms the diagnosis of tuberculosis by identifying the presence of Mycobacterium tuberculosis in the sputum sample. It is the gold standard for diagnosing active tuberculosis. Bronchoscopy (A) is invasive and used to visualize the airways, not for confirming TB diagnosis. Chest x-ray (C) may show characteristic findings of TB, but it does not confirm the diagnosis. Tuberculin skin test (D) only indicates exposure to TB bacteria, not active infection.
In pleurisy,
- A. some of the alveoli fill with fluid.
- B. the pleural membrane becomes inflamed and swollen and causes painful breathing.
- C. the diaphragm develops muscular cramps.
- D. the vagus nerve is irritated
Correct Answer: B
Rationale: The correct answer is B because pleurisy is inflammation of the pleural membrane, causing pain during breathing due to friction between the inflamed layers. Choice A is incorrect as alveoli are not directly affected in pleurisy. Choice C is incorrect as pleurisy does not cause cramps in the diaphragm. Choice D is incorrect as the vagus nerve irritation is not a characteristic feature of pleurisy.