Nokea
When examining the posterior pharynx and tonsils, which of the following objective data does the nurse note?
- A. Difficulty in sneezing
- B. Suppressed gag reflex
- C. Deformities
- D. Inflammation
Correct Answer: D
Rationale: The correct answer is D. Inflammation is a key finding during examination of the posterior pharynx and tonsils, especially in infections such as tonsillitis. A (difficulty in sneezing) is unrelated to pharyngeal assessment. B (suppressed gag reflex) might indicate neurological issues but isn't typically noted during routine exams. C (deformities) is rare unless there's structural abnormality.
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Miriam, a college student with acute rhinitis sees the campus nurse because of excessive nasal drainage. The nurse asks the patient about the color of the drainage. In acute rhinitis, nasal drainage normally is:
- A. Yellow
- B. Green
- C. Clear
- D. Gray
Correct Answer: C
Rationale: The correct answer is C: Clear. In acute rhinitis, the nasal drainage is typically clear because it is caused by viral infections or allergies, which result in clear mucus production. Yellow or green drainage may indicate a bacterial infection, which is not typically associated with acute rhinitis. Gray drainage is uncommon in nasal discharge and may suggest a more serious underlying condition. Therefore, the nurse asked about the color of the drainage to assess the nature of the infection and determine the appropriate course of treatment.
In which part of the body Mycobacterium tuberculosis affects
- A. Lungs
- B. Skin and Meninges
- C. Intestine
- D. All these
Correct Answer: D
Rationale: The correct answer is D. Mycobacterium tuberculosis primarily affects the lungs, causing tuberculosis. However, it can also spread to other parts of the body, such as the skin, leading to cutaneous tuberculosis, and the meninges, causing tuberculous meningitis. It can also affect the intestines, causing gastrointestinal tuberculosis. Therefore, the correct answer is D, as Mycobacterium tuberculosis can impact multiple parts of the body. Choice A (Lungs) is correct but does not encompass all the affected areas. Choices B (Skin and Meninges) and C (Intestine) are incorrect as they do not cover all the possible sites of infection by Mycobacterium tuberculosis.
A nurse working in a geriatric clinic sees clients with "cold" symptoms and rhinitis. The primary health care provider (PHCP) often leaves a prescription for diphenhydramine. What action by the nurse is best?
- A. Teach the client about possible drowsiness.
- B. Instruct the client to drink plenty of water.
- C. Consult with the PHCP about the medication.
- D. Encourage the client to take the medication with food.
Correct Answer: C
Rationale: The correct answer is C: Consult with the PHCP about the medication. This is the best action because diphenhydramine may not be the most appropriate medication for older adults due to potential side effects like increased risk of falls, confusion, and urinary retention. Consulting with the PHCP will ensure that the medication is safe and effective for the client.
A: Teaching about drowsiness is important but not the priority.
B: Drinking water is generally good advice but not specific to diphenhydramine.
D: Taking medication with food can help reduce stomach upset but doesn't address the concerns related to diphenhydramine in older adults.
A patient with a lung mass found on chest x-ray is undergoing further testing. The nurse explains that a diagnosis of lung cancer can be confirmed using which diagnostic test?
- A. Lung tomograms
- B. Pulmonary angiography
- C. Biopsy done via bronchoscopy
- D. Computed tomography (CT) scans
Correct Answer: C
Rationale: A biopsy done via bronchoscopy is a common method to confirm a diagnosis of lung cancer by obtaining tissue samples for analysis.
A client has experienced pulmonary embolism. A nurse assesses for which symptom, which is most commonly reported?
- A. Hot, flushed feeling.
- B. Sudden chills and fever.
- C. Chest pain that occurs suddenly.
- D. Nausea and vomiting.
Correct Answer: C
Rationale: The correct answer is C: Chest pain that occurs suddenly. Pulmonary embolism typically presents with sudden chest pain due to a blockage in the pulmonary arteries. This is a result of a blood clot traveling to the lungs, causing a sharp and stabbing pain. The other options are not typically associated with pulmonary embolism. A hot, flushed feeling (A) is more indicative of a fever or infection, sudden chills and fever (B) may occur in sepsis or the flu, and nausea and vomiting (D) are more commonly seen in gastrointestinal issues.