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When assessing a client with a history of asthma, which of the following factors should the nurse identify as a risk for asthma?
- A. Gender
- B. Environmental allergies
- C. Alcohol
- D. None of the above
Correct Answer: B
Rationale: When assessing a client with a history of asthma, the nurse should identify environmental allergies as a risk factor for asthma. Environmental allergens such as pollen, dust mites, mold, and pet dander can trigger asthma symptoms and exacerbate the condition. Gender, alcohol consumption, and other factors may not directly contribute to the development or exacerbation of asthma.
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A healthcare professional is assessing a client who has experienced a left-hemispheric stroke. Which of the following is an expected finding?
- A. Impulse control difficulty
- B. Poor judgement
- C. Inability to recognize familiar objects
- D. Loss of depth perception
Correct Answer: C
Rationale: Patients who have experienced a left-hemispheric stroke may exhibit symptoms of agnosia, which is the inability to recognize familiar objects or people. This occurs due to damage to the right hemisphere of the brain, which is responsible for visual and spatial perception. Impulse control difficulty, poor judgment, and loss of depth perception are not typically associated with left-hemispheric strokes.
When assessing a client with sinusitis, which technique should the nurse use to identify manifestations of this disorder?
- A. Percussion of the frontal sinuses
- B. Auscultation of the trachea
- C. Inspection of the nasal mucosa
- D. Palpation of the orbital areas
Correct Answer: D
Rationale: Sinusitis is an inflammation of the sinus cavities, which can cause tenderness and pain around the eyes (orbital areas). Palpation of the orbital areas can help identify tenderness and swelling associated with sinusitis. Auscultation of the trachea and percussion of the frontal sinuses are not relevant assessment techniques for sinusitis. Inspection of the nasal mucosa may reveal signs of inflammation, but palpation of the orbital areas is a more direct method to assess for tenderness and swelling in this specific condition.
A client is scheduled for a thoracentesis. Which of the following supplies should NOT be in the client's room?
- A. Oxygen equipment
- B. Incentive spirometer
- C. Pulse oximeter
- D. Sterile dressing
Correct Answer: B
Rationale: During a thoracentesis procedure, the focus is on draining fluid or air from the pleural space. An incentive spirometer, which helps improve lung function, is not a necessary supply for this specific procedure. Oxygen equipment, pulse oximeter for monitoring oxygen saturation levels, and sterile dressing for wound care may be needed during or after the procedure.
A nurse is orienting a newly licensed nurse on performing a routine assessment of a client who is receiving mechanical ventilation via an endotracheal tube. Which of the following information should the nurse include in the teaching?
- A. Apply a vest restraint if self-extubation is attempted.
- B. Monitor ventilator settings every 8 hours.
- C. Document tube placement in centimeters at the angle of the jaw.
- D. Assess breath sounds every 1 to 2 hours.
Correct Answer: D
Rationale: Assessing breath sounds every 1 to 2 hours is crucial in monitoring the client's respiratory status and identifying any potential complications promptly. Monitoring ventilator settings every 8 hours is important for overall ventilation management. Documenting the endotracheal tube placement accurately is essential to ensure proper positioning. Using a vest restraint if self-extubation is attempted is not a recommended intervention as it can lead to complications and should be avoided.
A group of clients are being educated about influenza. Which of the following client statements indicates an understanding of the teaching?
- A. ''I should wash my hands after blowing my nose to prevent spreading the virus.''
- B. ''I need to avoid drinking fluids if I develop symptoms.''
- C. ''I need a flu shot every 2 years because of the different flu strains.''
- D. ''I should cover my mouth with my hand when I sneeze.''
Correct Answer: A
Rationale: The correct answer is, 'I should wash my hands after blowing my nose to prevent spreading the virus.' This statement shows understanding of the importance of hand hygiene in preventing the spread of influenza. Washing hands after activities like blowing the nose can help reduce the risk of transmitting the virus to others. Choices B, C, and D are incorrect as they do not reflect accurate understanding of influenza prevention measures.