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When percussing over the lungs of a 4-year-old child, the nurse hears bilateral loud, long, and low tones. How should the nurse proceed?
- A. Palpate over the area for increased pain and tenderness.
- B. Ask the child to take shallow breaths and percuss over the area again.
- C. Refer the child to a specialist because of an increased amount of air in the lungs.
- D. Consider this finding as normal for a child this age and proceed with the examination.
Correct Answer: D
Rationale: In pediatric patients, loud, long, and low tones heard when percussing over the lungs are normal findings. These percussion notes are characteristic of a child's lung due to its thin chest wall and increased air content. It is unnecessary to palpate for pain and tenderness, ask the child to take shallow breaths and repeat the percussion, or refer the child to a specialist. Therefore, the correct action is to consider these findings as normal for the child's age and continue with the examination.
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When providing culturally competent care, nurses must incorporate cultural assessments into their health assessments. Which statement is most appropriate to use when initiating an assessment of cultural beliefs with an older American Indian patient?
- A. "Are you of the Christian faith?"?
- B. "Do you want to see a medicine man?"?
- C. "How often do you seek help from medical providers?"?
- D. "What cultural or spiritual beliefs are important to you?"?
Correct Answer: D
Rationale: The nurse needs to assess the cultural beliefs and practices of the patient and should ask questions in a way that communicates acceptance of their beliefs and allows for open communication. Therefore, the most appropriate question to initiate an assessment of cultural beliefs with an older American Indian patient is "What cultural or spiritual beliefs are important to you?"? This question shows respect for the patient's beliefs and encourages them to share relevant information. Asking if they are of the Christian faith does not promote open communication and may not reflect the patient's actual beliefs. While some American Indians may seek assistance from a medicine man or shaman, it is not appropriate to make assumptions without direct input from the patient. Asking how often they seek help from medical providers is not directly related to understanding their cultural beliefs and may not provide relevant insights for culturally competent care.
During an examination of a patient's abdomen, the nurse notes that the abdomen is rounded and firm to the touch. During percussion, the nurse notes a drum-like quality of the sounds across the quadrants. How would the nurse interpret this type of sound?
- A. Constipation
- B. Air-filled areas
- C. Presence of a tumor
- D. Presence of dense organs
Correct Answer: B
Rationale: A musical or drum-like sound (tympany) is heard when percussion occurs over an air-filled viscus, such as the stomach or intestines. This indicates the presence of air-filled areas. Constipation, choice A, does not produce specific percussion sounds and is related to bowel movements rather than the sound produced during percussion. The presence of a tumor, choice C, would not typically produce a drum-like sound but might result in dullness or decreased resonance. Dense organs, choice D, would produce a dull thud sound rather than a drum-like tympanic sound.
When examining an infant, which area should the nurse examine first?
- A. Ear
- B. Nose
- C. Throat
- D. Abdomen
Correct Answer: D
Rationale: When examining an infant, the nurse should start by examining the least-distressing areas first before moving on to more invasive areas. The abdomen is typically the least distressing area to examine, so it should be assessed first. Examining the eye, ear, nose, and throat are considered more invasive and should be saved for last. Therefore, the correct choice is to examine the abdomen first to ensure a comfortable and less distressing examination process for the infant. Choices A, B, and C (Ear, Nose, Throat) are more invasive areas and should be examined after the abdomen.
During an assessment, the nurse notices that a patient is handling a small charm that is tied to a leather strip around their neck. Which action by the nurse is appropriate?
- A. Ask the patient about the item and its significance.
- B. Ask the patient to lock the item with other valuables in the hospital's safe.
- C. Tell the patient that a family member should take valuables home.
- D. No action is necessary.
Correct Answer: A
Rationale: The small charm tied to a leather strip is likely an amulet, which many cultures consider an important means of protection from 'evil spirits.' When a patient appears to have a health practice the nurse is unfamiliar with, the nurse should ask for clarification in a non-judgmental way that communicates acceptance of their beliefs and allows for open communication. Thus, the nurse in this situation should inquire about the amulet's meaning to the patient. Asking the patient to lock the item with other valuables in the hospital's safe, telling the patient that a family member should take valuables home, or doing nothing does not address the importance or meaning of a cultural health practice to the patient and does not allow the nurse to gain an understanding of the patient's cultural health practices.
Which action is appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)?
- A. Listen to a patient's lung sounds for wheezes or rhonchi.
- B. Label specimens obtained during percutaneous lung biopsy.
- C. Instruct a patient about how to use home spirometry testing.
- D. Measure induration at the site of a patient's intradermal skin test.
Correct Answer: B
Rationale: Labeling specimens obtained during a percutaneous lung biopsy is a task that can be appropriately delegated to unlicensed assistive personnel (UAP) as it does not require nursing judgment. UAP can perform this task safely under the supervision of a nurse. Listening to a patient's lung sounds for wheezes or rhonchi, instructing a patient about how to use home spirometry testing, and measuring induration at the site of a patient's intradermal skin test all require nursing judgment and interpretation of findings. These tasks should be performed by licensed nursing personnel to ensure accurate assessment and appropriate intervention.