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What are the key signs of respiratory distress?
- A. Increased respiratory rate and use of accessory muscles
- B. Decreased respiratory rate and cyanosis
- C. Cyanosis and use of accessory muscles
- D. Altered mental status and bradycardia
Correct Answer: A
Rationale: The correct answer is A: Increased respiratory rate and use of accessory muscles are key signs of respiratory distress. When a person is experiencing respiratory distress, their respiratory rate typically increases as the body tries to compensate for the inadequate oxygenation. Additionally, the use of accessory muscles indicates that the person is working harder to breathe. Choices B, C, and D are incorrect because they do not accurately represent the key signs of respiratory distress. A decreased respiratory rate, cyanosis, altered mental status, and bradycardia are not typical signs of respiratory distress.
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A client with moderate anxiety disorder is being taught stress management techniques by a nurse. Which response by the client indicates an understanding of the teaching?
- A. I will take a walk to reduce my anxiety
- B. I will imagine myself in a calm place when I can't concentrate
- C. I will meditate every other week
- D. I will cut back on my caffeine intake
Correct Answer: B
Rationale: The correct answer is B because imagining oneself in a calm place is a relaxation technique that helps reduce anxiety. Walking, meditating every other week, or cutting back on caffeine intake may have their benefits, but they are not as directly related to the immediate management of anxiety as the visualization technique described in option B.
A nurse is caring for a client who has diabetes mellitus and is receiving insulin. Which of the following findings should the nurse report to the provider?
- A. A fasting blood glucose of 90 mg/dL
- B. A blood glucose level of 200 mg/dL
- C. A hemoglobin A1c of 6%
- D. A fasting blood glucose of 100 mg/dL
Correct Answer: B
Rationale: The correct answer is B. A blood glucose level of 200 mg/dL indicates hyperglycemia, which may necessitate insulin adjustment to better control the client's blood sugar levels. A fasting blood glucose of 90 mg/dL (choice A) is within the normal range, a hemoglobin A1c of 6% (choice C) is indicative of good long-term blood sugar control, and a fasting blood glucose of 100 mg/dL (choice D) is also within the normal range. Therefore, these findings do not require immediate reporting to the provider.
A nurse is assessing the remote memory of an older adult client who has mild dementia. Which of the following questions should the nurse ask the client?
- A. Can you tell me who visited you today?
- B. What high school did you graduate from?
- C. Can you list your current medications?
- D. What did you have for breakfast yesterday?
Correct Answer: B
Rationale: The correct answer is B: 'What high school did you graduate from?' Remote memory involves recalling past events, such as educational history, making option B the most appropriate question to assess this aspect of memory in an older adult with mild dementia. Option A pertains to recent memory. Option C focuses on short-term memory. Option D addresses recent memory as well.
A nurse is teaching a client who is to undergo radiation therapy for breast cancer about potential adverse effects. Which of the following adverse effects should the nurse include in the teaching?
- A. Fatigue
- B. Constipation
- C. Hair loss
- D. Weight gain
Correct Answer: A
Rationale: The correct adverse effect that the nurse should include in the teaching is fatigue. Fatigue is a common side effect of radiation therapy, particularly with prolonged treatment. Constipation, hair loss, and weight gain are not typically associated with radiation therapy for breast cancer, making them incorrect choices. Fatigue can significantly impact a patient's quality of life during treatment and should be addressed proactively by healthcare providers.
A nurse is teaching a client who has chronic obstructive pulmonary disease (COPD) about breathing exercises. Which of the following instructions should the nurse include?
- A. Use abdominal breathing during physical activity
- B. Inhale quickly and deeply through the nose
- C. Use pursed-lip breathing during physical activity
- D. Breathe quickly and deeply during exercise
Correct Answer: C
Rationale: The correct answer is C: 'Use pursed-lip breathing during physical activity.' Pursed-lip breathing is a beneficial technique for clients with COPD as it helps improve airflow by keeping the airways open longer. Choice A is incorrect as abdominal breathing may not be as effective in COPD as pursed-lip breathing. Choice B, inhaling quickly and deeply through the nose, is not recommended as it can lead to hyperventilation. Choice D, breathing quickly and deeply during exercise, is also not suitable for clients with COPD as it can cause increased shortness of breath.