Nokea
Where is the appropriate placement of a tongue blade for assessment of the mouth and throat?
- A. Center back area of tongue
- B. Side of the tongue
- C. Against the soft palate
- D. On the lower jaw
Correct Answer: A
Rationale: The appropriate placement of a tongue blade for assessment of the mouth and throat is at the center back area of the tongue. This location allows the healthcare provider to depress the tongue gently to have a clear view of the oral cavity, tonsils, and throat structures. Placing the tongue blade on the side of the tongue may not provide adequate visualization, and placing it against the soft palate or on the lower jaw would not help in examining the mouth and throat effectively.
You may also like to solve these questions
A 34 year old male client is diagnosed with encephalitis. Medication has been started for him and he is receiving nursing care. Which of the ff nursing interventions are the most critical for such a client? Choose all that apply
- A. Measuring fluid intake and output
- B. Evaluating the clients ventilation capacity and lung sound frequently
- C. Observing closely for signs of respiratory distress
- D. Administering an indwelling urethral catheter
Correct Answer: B
Rationale: B. Evaluating the client's ventilation capacity and lung sounds frequently is crucial in encephalitis because the inflammation of the brain can affect the respiratory center, leading to respiratory compromise. Any changes in ventilation capacity or abnormal lung sounds should be addressed immediately to prevent respiratory distress.
.A client complains of urinary discomfort and a burning sensation while urinating. A urethral smear shows evidence of urethritis, and the client is prescribed antibiotics and instructed to drink 2-3 L of water daily. For which of the ff reasons is the client advised to drink the specified amount of water?
- A. It will help him overcome urinary incontinence
- B. It will promote renal blood flow and flush bacteria from the urinary tract
- C. It will help him eliminate urinary odors
- D. It will provide relief from pain and discomfort as a result of urinary tract infection DISTURBANCES IN FLUIDS AND ELECTROLYTES
Correct Answer: B
Rationale: The client is advised to drink 2-3 liters of water daily because it will promote renal blood flow and flush bacteria from the urinary tract. Increased water intake helps to dilute the urine, making it easier to flush out harmful bacteria that may be causing the urinary discomfort and urethritis. Adequate hydration is crucial for maintaining healthy urinary function and preventing urinary tract infections. By increasing water consumption, the client can help reduce the concentration of bacteria in the urinary tract, supporting the effectiveness of the prescribed antibiotics in treating the urethritis.
A nurse is preparing to feed a 12-month-old infant with failure to thrive. Which intervention should the nurse implement?
- A. Provide stimulation during feeding.
- B. Avoid being persistent during feeding time.
- C. Limit feeding time to 10 minutes.
- D. Maintain a face-to-face posture with the infant during feeding.
Correct Answer: A
Rationale: Providing stimulation during feeding is the most appropriate intervention for a 12-month-old infant with failure to thrive. Infants with failure to thrive may have decreased interest in feeding or difficulty with obtaining adequate nutrition. By providing stimulation during feeding, such as making eye contact, talking gently, and playing soft music, the nurse can help increase the infant's interest and engagement in feeding. This can lead to improved feeding outcomes and help the infant receive the necessary nutrition for growth and development.
Which is the most common cause of acute renal failure in children?
- A. Pyelonephritis
- B. Tubular destruction
- C. Urinary tract obstruction
- D. Inadequate perfusion
Correct Answer: D
Rationale: Inadequate perfusion, usually due to conditions such as shock or severe dehydration, is the most common cause of acute renal failure in children. Reduced blood flow to the kidneys impairs their ability to function properly and filter waste products from the blood. This can lead to a rapid decline in kidney function and the development of acute renal failure. Other potential causes such as pyelonephritis, tubular destruction, and urinary tract obstruction can also result in acute renal failure, but inadequate perfusion is the most common trigger, especially in pediatric patients.
A few minutes after beginning a blood transfusion, the nurse notes that the client has chills, dyspnea, and urticaria. The nurse reports this to the physician immediately because the client probably is experiencing which problem?
- A. A hemolytic reaction to mismatched blood
- B. A hemolytic reaction to Rh-incompatible blood
- C. A hemolytic allergic reaction caused by bacterial contamination of donor blood
- D. None of the above
Correct Answer: A
Rationale: The client is likely experiencing a hemolytic reaction to mismatched blood due to the symptoms of chills, dyspnea, and urticaria occurring shortly after beginning the blood transfusion. These symptoms are classic signs of a transfusion reaction, especially a hemolytic reaction where the recipient's immune system attacks the transfused red blood cells. This can happen if the donor blood is not compatible with the recipient's blood type, leading to a severe reaction. It is crucial to report this immediately to the physician to halt the transfusion and provide appropriate treatment to the client.