Nokea
When a nurse asks a client to repeat the word 'ninety-nine' while listening through the stethoscope and is able to hear the word clearly, which assessment finding is being documented?
- A. Normal egophony
- B. Abnormal vesicular breath sounds
- C. Abnormal bronchophony
- D. Normal whispered pectoriloquy
Correct Answer: C
Rationale: The nurse is documenting an abnormal bronchophony assessment finding. Bronchophony is a technique where the nurse asks the client to repeat a specific word, such as 'ninety-nine,' while listening through the stethoscope. Normally, the voice transmission is soft, muffled, and indistinct. However, if there is a pathologic condition increasing lung density, the nurse will hear the word clearly, indicating an abnormality. Vesicular breath sounds are normal sounds heard over peripheral lung fields and are not related to vocal resonance assessment. Egophony involves the client phonating a long 'ee-ee-ee-ee' sound, not repeating a specific word. Whispered pectoriloquy involves whispering a phrase like 'one-two-three,' not repeating a specific word. In these cases, normal findings are 'eeeeee' for egophony and a muffled, almost inaudible sound for whispered pectoriloquy.
You may also like to solve these questions
When caring for pediatric clients, the nurse should pay special attention to the psychosocial development stages credited to whom?
- A. Robert Peck
- B. Erik Erikson
- C. Sigmund Freud
- D. Jean Piaget
Correct Answer: B
Rationale: Erik Erikson is credited with the psychosocial development theory and eight stages. The nurse should consider these stages when caring for pediatric clients to evaluate their development. Jean Piaget is known for cognitive development, Sigmund Freud for psychosexual development, and Robert Peck for aging theory. Therefore, the correct answer is Erik Erikson.
A nurse is preparing to assess the dorsalis pedis pulse. The nurse palpates this pulse by placing the fingertips in which location?
- A. Behind the knee
- B. Lateral to the extensor tendon of the big toe
- C. In the groove between the malleolus and the Achilles tendon
- D. Below the inguinal ligament, halfway between the pubis and the anterior superior iliac spines
Correct Answer: B
Rationale: The correct location to palpate the dorsalis pedis pulse is lateral to and parallel with the extensor tendon of the big toe. Choices A, C, and D describe the locations for other pulses - popliteal, posterior tibial, and femoral artery respectively. The popliteal pulse is found behind the knee, the posterior tibial pulse is located in the groove between the malleolus and the Achilles tendon, and the femoral artery is situated below the inguinal ligament, halfway between the pubis and the anterior superior iliac spines.
The LPN is preparing a client for discharge, and the discharge medications include phenobarbital. Which of these client statements would indicate a need for reinforced teaching about this medication?
- A. "I will need to avoid eating excessive leafy greens."?
- B. "It's best to take this medication with food."?
- C. "I can't wait to get back to my nightly glass of wine."?
- D. "I should try to take this medication at the same time every day."?
Correct Answer: C
Rationale: The correct answer is, "I can't wait to get back to my nightly glass of wine,"? as phenobarbital should not be taken with alcohol as it is a barbiturate. Alcohol may increase the sedative effect, posing risks to the patient's safety. Choice A, "I will need to avoid eating excessive leafy greens,"? is unrelated to phenobarbital and not a cause for reinforced teaching. Choice B, "It's best to take this medication with food,"? is a general instruction and not specific to phenobarbital. Choice D, "I should try to take this medication at the same time every day,"? is a common recommendation for medication adherence but does not highlight a specific concern related to phenobarbital.
When a woman is receiving postpartum epidural morphine, the nurse should plan to observe for which of the following side effects to occur within the first 3 hours?
- A. nausea and vomiting
- B. itching
- C. urinary retention
- D. somnolence
Correct Answer: B
Rationale: A side effect of postpartum epidural morphine is the onset of itching within 3 hours of injection and lasting up to 10 hours. Nausea and vomiting might occur 4-7 hours after injection. Urinary retention is a side effect of postpartum epidural morphine but is not assessed as such within the first 3 hours. Somnolence is a rare side effect.
A client describes her cervical mucus as clear, thin, and elastic. Upon examination, the nurse demonstrates that the cervical mucus can be stretched 8-10 cm. The nurse correctly documents the finding as:
- A. increased ferning capacity.
- B. lack of ferning.
- C. spinnbarkheit.
- D. inhospitable.
Correct Answer: C
Rationale: The nurse should document the finding as 'spinnbarkheit.' Spinnbarkheit is the term used to describe the clear, thin, and elastic cervical mucus that can be stretched 8-10 cm, indicating ovulation. It helps couples determine the most fertile period for conception. Ferning capacity or crystallization increases as ovulation approaches, but it requires microscopic examination to be confirmed. Lack of ferning cannot be determined without such examination. 'Inhospitable' cervical mucus refers to patterns that prohibit sperm motility, caused by various factors like hormone levels or infection. These conditions cannot be assessed based solely on the description provided in the question.