Nokea
What general appearance and obvious physical characteristic components should the nurse evaluate when completing a biocultural assessment?
- A. Skin color,bone structure and eye shape.
- B. Mobility and gait.
- C. Behavioral patterns.
- D. All of the above.
Correct Answer: D
Rationale: Evaluating multiple aspects of physical appearance provides a comprehensive understanding of the client's biocultural context.
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Following segmental resection for bronchiectasis, what is most important for Mr. Jones?
- A. Cough and deep breathe every 1-2 hours
- B. Limit fluid intake
- C. Lie flat in bed
- D. Receive analgesia every 6 hours
Correct Answer: A
Rationale: Regular coughing and deep breathing prevent atelectasis and pneumonia.
A 29-year-old client is admitted for a hysterectomy and is expressing concern regarding the procedure. Shortly into the preoperative teaching, the client complains of a tightness in the chest, feelings of suffocation, light-headedness, and tingling in the hands. The client's respirations are rapid and deep. The nursing assessment reveals that this client is:
- A. having a heart attack.
- B. wanting attention from the nurses.
- C. suffering from complete upper airway obstruction.
- D. hyperventilating.
Correct Answer: D
Rationale: Classic symptoms of a heart attack include a heaviness or squeezing pain in the chest, pain spreading to the jaw, neck, and arm. Nausea and vomiting, sweating, and shortness of breath may also be present. However, the client does not exhibit these symptoms. Clients suffering from anxiety or fear prior to surgical procedures may develop hyperventilation. This client is not seeking attention. Symptoms of complete airway obstruction include not being able to speak, lack of airflow between the nose and mouth, and absent breath sounds. A tightness in the chest, feelings of suffocation, light-headedness, tingling in the hands, and rapid deep respirations are signs and symptoms of hyperventilation, which is almost always a manifestation of anxiety.
Mary, who is scheduled for a thoracentesis, asks why there is so much fluid in the pleural space. You respond by saying
- A. Your body is unable to remove fluid, resulting in a buildup of fluid in the pleural space around your lungs.
- B. An error occurred and you were administered too much IV medication.
- C. This is the result of oxygen therapy.
- D. This is a normal side effect of bumetanide, which is medication ordered by your physician.
Correct Answer: A
Rationale: Fluid accumulation in the pleural space can occur due to various conditions like heart failure or infection.
If the patient becomes discouraged during the rehabilitation program, what should the nurse do?
- A. Tell the family that the patient has not adjusted
- B. Stop the rehabilitative program until the patient is more optimistic
- C. Listen to his complaints and continue to encourage him
- D. Ignore his complaints and continue with the rehabilitation efforts
Correct Answer: C
Rationale: Active listening and encouragement help maintain motivation and adherence to the rehabilitation program.
Why should the nurse closely monitor older adults when they are receiving IV therapy?
- A. Because their defense mechanisms are less efficient.
- B. Because they are prone to fluid overload.
- C. Because they are prone to increased renal efficiency.
- D. Because they have inadequate intake of dietary fiber.
Correct Answer: B
Rationale: The correct answer is B because older adults are more prone to fluid overload due to reduced kidney function.