Nokea
The nurse plans health care for a community with a large number of recent immigrants from Vietnam. Which intervention is the most important for the nurse to implement?
- A. Hepatitis testing
- B. Tuberculosis screening
- C. Contraceptive teaching
- D. Colonoscopy information
Correct Answer: B
Rationale: Tuberculosis (TB) is prevalent in many parts of Asia, including Vietnam, and the incidence of TB is higher in immigrants from Vietnam compared to the general U.S. population. Conducting tuberculosis screening is crucial to identify and address any cases promptly, especially in a community with recent immigrants from Vietnam. While teaching about contraceptive use, providing colonoscopy information, and testing for hepatitis may be relevant for certain individuals in the community, they are not as universally important as tuberculosis screening due to the increased risk of TB among Vietnamese immigrants.
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The pediatric nurse caring for a 3-year-old child with cerebral palsy (CP) prepares a home care teaching plan for the caregivers on discharge. Which items will the nurse include in the teaching plan? (Select one that does not apply.)
- A. Apply splints and braces to facilitate muscle control.
- B. Buy toys that are appropriate for the child's abilities.
- C. Encourage the child to perform self-care tasks.
- D. Use skeletal muscle relaxants for short-term control.
Correct Answer: D
Rationale: When developing a discharge teaching plan for a child with cerebral palsy (CP), the nurse should focus on strategies to enhance the child's independence and functional abilities. Choices A, B, and C are appropriate interventions to include in the teaching plan for a child with CP. Applying splints and braces can help facilitate muscle control and improve body functioning. Buying toys that are appropriate for the child's abilities can promote engagement and development. Encouraging the child to perform self-care tasks fosters independence and skill development. However, the use of skeletal muscle relaxants for short-term control is not typically a part of routine care for pediatric patients with CP. These medications are usually reserved for specific situations and are not a standard component of home care teaching plans for children with CP.
Using the illustrated technique, the healthcare provider is assessing for which finding in a patient with chronic obstructive pulmonary disease (COPD)?
- A. Hyperresonance
- B. Tripod positioning
- C. Accessory muscle use
- D. Reduced chest expansion
Correct Answer: D
Rationale: The technique for palpation for chest expansion is shown in the illustrated technique. Reduced chest expansion would be noted on palpation of a patient's chest with COPD. Hyperresonance would be assessed through percussion, not palpation. Accessory muscle use and tripod positioning would be assessed by inspection, not palpation.
Claudication is a well-known effect of peripheral vascular disease. Which of the following facts about claudication is correct? Select the one that doesn't apply:
- A. It results when oxygen demand is greater than oxygen supply.
- B. It is characterized by pain that often occurs during rest.
- C. It is a result of tissue hypoxia.
- D. It is characterized by cramping and weakness.
Correct Answer: D
Rationale: Claudication is a symptom of peripheral vascular disease where there is an inadequate supply of oxygen to the muscles due to reduced blood flow. This mismatch between oxygen demand and supply leads to tissue hypoxia, resulting in cramping, weakness, and discomfort. Option D correctly states that claudication is characterized by cramping and weakness, making it the correct answer. Options A, B, and C are incorrect. Claudication occurs when oxygen demand exceeds supply, not the other way around as stated in Option A. Pain in claudication typically occurs with activity, not at rest as mentioned in Option B. While tissue hypoxia is a consequence of claudication, it is not the primary cause, making Option C incorrect.
A patient with severe mitral regurgitation and decreased cardiac output is being cared for by a nurse. The nurse assesses the patient for mental status changes. What is the rationale for this intervention?
- A. Decreased cardiac output can cause hypoxia to the brain
- B. Mental status changes may be a side effect of the patient's medication
- C. Mitral regurgitation is a complication associated with some neurological disorders
- D. The patient may be confused about his diagnosis
Correct Answer: A
Rationale: When caring for a patient with severe mitral regurgitation and decreased cardiac output, assessing for mental status changes is crucial. Decreased cardiac output can lead to inadequate perfusion and oxygenation of vital organs, including the brain, resulting in hypoxia. This hypoxia can manifest as mental status changes such as confusion, restlessness, or lethargy. Therefore, monitoring mental status helps in identifying potential hypoxic states and guiding appropriate interventions. The other options are incorrect as they do not directly correlate decreased cardiac output with potential hypoxia-induced mental status changes.
The nurse monitors a patient after chest tube placement for a hemopneumothorax. The nurse is most concerned if which assessment finding is observed?
- A. A large air leak in the water-seal chamber
- B. 400 mL of blood in the collection chamber
- C. Complaint of pain with each deep inspiration
- D. Subcutaneous emphysema at the insertion site
Correct Answer: B
Rationale: The nurse should be most concerned if 400 mL of blood is observed in the collection chamber as it may indicate the patient is at risk of developing hypovolemic shock. A large air leak in the water-seal chamber is expected initially after chest tube placement for a pneumothorax. While pain with deep inspiration should be treated, it is not as urgent as the risk of continued hemorrhage. Subcutaneous emphysema is not uncommon in a patient with pneumothorax and is usually harmless. However, a large amount of blood in the collection chamber is a more critical finding that requires immediate attention to prevent potential complications.