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The nurse is reviewing the record of a client with a disorder involving the inner ear. Which finding should the nurse most likely note as an assessment finding in this client?
- A. Tinnitus
- B. Burning in the ear
- C. Itching in the affected ear
- D. Severe pain in the affected ear
Correct Answer: A
Rationale: Tinnitus is the most common complaint of clients with ear disorders, especially disorders involving the inner ear. Manifestations of tinnitus can range from mild ringing in the ear that can go unnoticed during the day to a loud roaring in the ear that can interfere with the client's thinking process and attention span. The assessment findings noted in options 2, 3, and 4 are not specifically noted in the client with an inner ear disorder.
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A prenatal client has been diagnosed with a vaginal infection from the organism Candida albicans. What should the nurse expect to note on assessment of the client?
- A. Costovertebral angle pain
- B. Absence of any observable signs
- C. Pain, itching, and vaginal discharge
- D. Proteinuria, hematuria, and hypertension
Correct Answer: C
Rationale: Clinical manifestations of a Candida infection include pain; itching; and a thick, white vaginal discharge. Proteinuria and hypertension are signs of preeclampsia. Costovertebral angle pain, proteinuria, and hematuria are clinical manifestations associated with upper urinary tract infections.
The home care nurse assesses a client diagnosed with chronic obstructive pulmonary disease (COPD) who is reporting increased dyspnea. The client is on home oxygen via a concentrator at 2 L per minute, and has a respiratory rate of 22 breaths per minute. Which action should the nurse take?
- A. Determine the need to increase the oxygen.
- B. Reassure the client that there is no need to worry.
- C. Conduct further assessment of the client's respiratory status.
- D. Call emergency services to take the client to the emergency department.
Correct Answer: C
Rationale: With the client's respiratory rate at 22 breaths per minute, the nurse should obtain further assessment. Oxygen is not increased without the approval of the primary health care provider, especially because the client with COPD can retain carbon dioxide. Reassuring the client that there is 'no need to worry' is inappropriate. Calling emergency services is a premature action.
The nurse hangs an intravenous (IV) bag of 1000 mL of 5% dextrose in water (D5W) at 3 pm and sets the flow rate to infuse at 75 mL/hour. At 11 pm, the nurse should expect the fluid remaining in the IV bag to be at approximately which level?
Correct Answer: 400 mL
Rationale: In an 8-hour period, 600 mL would infuse if an IV is set to infuse at 75 mL/hour. Therefore, 400 mL would remain in the IV bag.
A client is brought into the emergency department after sustaining a possible closed head injury. Which assessment will the nurse perform first?
- A. Level of consciousness
- B. Pulse and blood pressure
- C. Respiratory rate and depth
- D. Ability to move extremities
Correct Answer: C
Rationale: The first action of the nurse is to ensure that the client has an adequate airway and respiratory status. In rapid sequence, the client's circulatory status is evaluated (option 2), followed by evaluation of the status of the cardiovascular and neurological systems.
The nurse performing a prenatal assessment on a client in the first trimester of pregnancy discovers that the client frequently consumes beverages containing alcohol. Why should the nurse initiate interventions immediately to assist the client in avoiding alcohol consumption?
- A. To reduce the potential for fetal growth restriction in utero
- B. To promote the normal psychosocial adaptation of the mother to pregnancy
- C. To minimize the potential for placental abruptions during the intrapartum period
- D. To reduce the risk of teratogenic effects to embryo's developing fetal organs and tissue
Correct Answer: D
Rationale: Alcohol consumption during the first trimester poses a significant risk for teratogenic effects, as this is a critical period for organogenesis in the developing embryo. Exposure to alcohol can lead to fetal alcohol syndrome or other congenital anomalies, making immediate intervention essential to protect fetal development. While fetal growth restriction, psychosocial adaptation, and placental abruption are concerns, they are less directly associated with early pregnancy alcohol exposure compared to teratogenic effects.