Nokea
When obtaining a health history from a 76-year-old patient with suspected CAP, what does the nurse expect the patient or caregiver to report?
- A. Confusion
- B. An abrupt onset of fever and chills
- C. A recent loss of consciousness
- D. A gradual onset of headache and sore throat
Correct Answer: B
Rationale: In patients with Community-Acquired Pneumonia (CAP), an abrupt onset of fever and chills is a common symptom to expect. This is due to the rapid inflammatory response in the lungs. Confusion, loss of consciousness, and gradual headache and sore throat are less likely to be reported initially.
You may also like to solve these questions
Nurse Maureen has assisted a physician with the insertion of a chest tube. The nurse monitors the client and notes fluctuation of the fluid level in the water seal chamber after the tube is inserted. Based on this assessment, which action would be appropriate?
- A. Inform the physician.
- B. Continue to monitor the client.
- C. Reinforce the occlusive dressing.
- D. Encourage the client to deep breathe.
Correct Answer: B
Rationale: The correct answer is B: Continue to monitor the client. Fluctuation of fluid level in the water seal chamber post chest tube insertion indicates proper functioning of the chest tube system. This signifies that the tube is effectively draining fluid or air from the pleural space. It is essential to continue monitoring the client to ensure ongoing proper functioning of the chest tube. Informing the physician (Choice A) is not necessary at this point unless there are other concerning symptoms. Reinforcing the occlusive dressing (Choice C) is not indicated unless there is a leak or issue with the dressing. Encouraging the client to deep breathe (Choice D) is unrelated to the assessment of the chest tube system.
Double Bohr effect (Oxygen curves for maternal and foetal Hb move apart in opposite directions) occurs in
- A. Foetal circulation
- B. Maternal circulation
- C. In the Placenta operating in both maternal and foetal circulations
- D. In the uterine wall
Correct Answer: C
Rationale: Rationale:
1. In the placenta, maternal and fetal blood circulations are in close proximity.
2. Maternal Hb releases oxygen to fetal Hb due to the lower affinity of fetal Hb for oxygen.
3. This double Bohr effect causes the oxygen dissociation curves of maternal and fetal Hb to move apart.
4. This occurs specifically in the placenta where both maternal and fetal circulations operate.
Summary:
A. Incorrect. Double Bohr effect doesn't occur solely in fetal circulation.
B. Incorrect. Double Bohr effect doesn't occur solely in maternal circulation.
C. Correct. Placenta facilitates the exchange between maternal and fetal blood causing the double Bohr effect.
D. Incorrect. Double Bohr effect is not related to the uterine wall.
A nurse cares for a client who had a partial laryngectomy 10 days ago. The client states that all food tastes bland. How would the nurse respond?
- A. I will consult the speech therapist to ensure you are swallowing properly.
- B. This is normal after surgery. What types of food do you like to eat?
- C. I will ask the dietitian to change the consistency of the food in your diet.
- D. Replacement of protein, calories, and water is very important after surgery.
Correct Answer: B
Rationale: Step 1: Acknowledge client's concern about bland taste.
Step 2: Validate normalcy post-laryngectomy.
Step 3: Assess client's food preferences for individualized care.
Step 4: Encourage open communication for effective care plan.
Step 5: Addressing the issue holistically promotes client-centered care.
Summary:
- A: Focuses on swallowing, not taste.
- C: Addresses food consistency, not taste.
- D: Important but not directly related to client's concern.
When the diaphragm and external intercostals muscles contract, which of the following actions does NOT occur?
- A. air moves into the lung
- B. the intrapleural pressure increases
- C. the diaphragm moves inferiorly
- D. the intrapulmonary pressure decreases
Correct Answer: B
Rationale: When the diaphragm and external intercostals contract, the thoracic cavity expands, causing the lungs to expand and the intrapulmonary pressure to decrease (choice D). This decrease in pressure allows air to flow into the lungs (choice A). The diaphragm moves inferiorly during contraction, not superiorly (choice C). The intrapleural pressure actually decreases when these muscles contract, not increases, due to increased thoracic volume and decreased intrapleural pressure acting as a suction to keep the lungs inflated (choice B). Therefore, the correct answer is B, as the intrapleural pressure actually decreases when the diaphragm and external intercostals contract.
The nurse assesses wheezes in a patient with asthma and realizes that these breath sounds result from:
- A. Increased thickness of respiratory secretions.
- B. Use of accessory muscles of respiration.
- C. Tachypnea and tachycardia.
- D. Movement of air through narrowed airways.
Correct Answer: D
Rationale: The correct answer is D because wheezes in asthma are caused by the movement of air through narrowed airways due to bronchoconstriction and inflammation. This narrowing leads to turbulent airflow, resulting in the characteristic high-pitched musical sound of wheezes. Increased thickness of respiratory secretions (A) may cause crackles, not wheezes. Use of accessory muscles (B) indicates respiratory distress but does not directly cause wheezes. Tachypnea and tachycardia (C) are common in asthma but do not directly cause wheezes. Thus, D is the most directly related to the pathophysiology of wheezes in asthma.