Nokea
To assess the quality of an adult client's pain, what approach should the nurse use?
- A. Observe body language and movement.
- B. Ask the client to describe the pain.
- C. Identify effective pain relief measures.
- D. Provide a numeric pain scale.
Correct Answer: B
Rationale: The correct answer is to ask the client to describe the pain. This approach allows the nurse to gather subjective information directly from the client, such as the quality, intensity, location, and factors that aggravate or alleviate the pain. Observing body language and movement (Choice A) can provide additional cues but may not fully capture the client's pain experience. Identifying effective pain relief measures (Choice C) and providing a numeric pain scale (Choice D) are important aspects of pain management but do not directly assess the quality of the client's pain.
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A client tells the clinic nurse about experiencing burning on urination, and assessment reveals that the client had sexual intercourse four days ago with a person who was casually met. Which action should the nurse implement?
- A. Observe the perineal area for a chancroid-like lesion
- B. Obtain a specimen of urethral drainage for culture
- C. Assess for perineal itching, erythema, and excoriation
- D. Identify all sexual partners in the last four days
Correct Answer: B
Rationale: Obtaining a urethral drainage specimen for culture is crucial in diagnosing a potential sexually transmitted infection (STI) in this client. While assessing for perineal symptoms like itching, erythema, and excoriation (Choice C) may provide additional information, obtaining a culture is more definitive. Observing for a chancroid-like lesion (Choice A) is not as pertinent as obtaining a culture for a broader diagnostic approach. Identifying all sexual partners in the last four days (Choice D) is important for contact tracing but obtaining a specimen for culture takes priority in this scenario.
What do crackles heard on lung auscultation indicate?
- A. Cyanosis.
- B. Bronchospasm.
- C. Airway narrowing.
- D. Fluid-filled alveoli.
Correct Answer: D
Rationale: Crackles heard on lung auscultation are caused by the popping open of small airways that are filled with fluid. This is commonly associated with conditions such as pulmonary edema, pneumonia, or heart failure. Cyanosis (Choice A) is a bluish discoloration of the skin and mucous membranes due to low oxygen levels in the blood, not directly related to crackles. Bronchospasm (Choice B) refers to the constriction of the airway smooth muscle, causing difficulty in breathing but does not typically produce crackles. Airway narrowing (Choice C) can lead to wheezing but is not directly linked to crackles heard on auscultation.
Which food is most important to encourage a client with osteomalacia to include in a daily diet?
- A. Fortified milk and cereals
- B. Citrus fruits and juices
- C. Green leafy vegetables
- D. Red meats and eggs
Correct Answer: A
Rationale: The correct answer is A: Fortified milk and cereals. Osteomalacia is a condition caused by a deficiency in vitamin D. Fortified milk and cereals are rich sources of vitamin D, which is essential for managing osteomalacia. Citrus fruits and juices (choice B) are high in vitamin C, but vitamin D is the primary concern for osteomalacia. Green leafy vegetables (choice C) are good sources of various nutrients but not the main focus for managing osteomalacia. Red meats and eggs (choice D) are good sources of protein and other nutrients but are not as critical as fortified milk and cereals for addressing vitamin D deficiency in osteomalacia.
A client diagnosed with a history of asthma and bronchitis arrives at the clinic with shortness of breath, productive cough with thickened, tenacious mucus, and the inability to walk up a flight of stairs without experiencing breathlessness. Which action is most important for the nurses to instruct the client about self-care?
- A. Call the clinic if undesirable side effects of medications occur
- B. Avoid crowded enclosed areas to reduce pathogen exposure
- C. Increase the daily intake of oral fluids to liquefy secretions
- D. Teach anxiety reduction methods for feelings of suffocation
Correct Answer: C
Rationale: Increasing the daily intake of oral fluids is crucial for clients with asthma and bronchitis as it helps to liquefy thickened mucus, making it easier to clear the airways and manage symptoms. This self-care measure can improve the client's ability to breathe more effectively. Choice A is not the most immediate concern when addressing thickened mucus and breathing difficulties. While avoiding crowded areas is beneficial to prevent respiratory infections, it is not directly related to managing thickened secretions. Teaching anxiety reduction methods is important for overall well-being, but it does not directly address the physiological issue of thickened mucus in the airways.
A client with partial thickness burns to the lower extremities is scheduled for whirlpool therapy to debride the burned area. Which intervention should the nurse implement before transporting the client to the physical therapy department?
- A. Obtain supplies to re-dress the burn area.
- B. Verify the client's signed consent form.
- C. Give a prescribed narcotic analgesic agent.
- D. Perform active range-of-motion exercises.
Correct Answer: C
Rationale: Before transporting the client for whirlpool therapy to debride the burned area, the nurse should give a prescribed narcotic analgesic agent. This intervention is essential to manage pain effectively during the debridement process. Obtaining supplies to re-dress the burn area (Choice A) is important but not as immediate as providing pain relief. Verifying the client's signed consent form (Choice B) is necessary for procedures but does not address the client's immediate pain needs. Performing active range-of-motion exercises (Choice D) is not indicated before whirlpool therapy for debridement of burns and may cause further discomfort to the client.