Nokea
Which assessment finding signals the most serious and life-threatening condition?
- A. A deviated trachea
- B. Gross deformity in a lower extremity
- C. Decreased breath sounds
- D. Hemoptysis
Correct Answer: A
Rationale: A deviated trachea indicates possible tension pneumothorax, a life-threatening condition.
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While on a hiking trip, Mr. Jones states that a branch of a tree struck his eye. Part of the branch remains lodged in the eye, and the eyelid is bleeding. Appropriate emergency treatment would include
- A. covering the eye with a protective shield
- B. encouraging Mr. Jones to hold his eye closed tightly
- C. applying a pressure dressing to the eye
- D. removing the foreign body and applying a sterile dressing
Correct Answer: A
Rationale: Covering the eye with a protective shield prevents further injury while awaiting professional medical evaluation and removal of the foreign object.
When assessing a client with anxiety disorder, what does the nurse observe for evidence of various levels of anxiety?
- A. Absence of crying
- B. Talking excessively
- C. Being motionless
- D. Not complaining
Correct Answer: B
Rationale: Excessive talking may indicate heightened anxiety as the client attempts to distract themselves from their worries.
A healthcare professional is assessing a client with rheumatoid arthritis. Which assessment finding is most characteristic of this disease?
- A. Asymmetrical joint involvement
- B. Heberden's nodes
- C. Morning stiffness lasting more than 30 minutes
- D. Pain that worsens with activity
Correct Answer: C
Rationale: The correct answer is C: Morning stiffness lasting more than 30 minutes. This is characteristic of rheumatoid arthritis due to the inflammatory nature of the disease. The prolonged morning stiffness is a hallmark feature, reflecting the systemic inflammation present in rheumatoid arthritis. This symptom is not typically seen in osteoarthritis, which rules out options A and B. Pain that worsens with activity is more indicative of osteoarthritis as opposed to rheumatoid arthritis, making option D incorrect.
The nurse is teaching a client who has a hip prostheses following total hip replacement. Which of the following should be included in the instructions for home care?
- A. Avoid climbing stairs for 3 months.
- B. Ambulate using crutches only.
- C. Sleep only on your back.
- D. Do not cross legs.
Correct Answer: D
Rationale: Crossing legs can dislocate the hip prosthesis.
What is a common cause of sensorineural hearing loss?
- A. Otitis media
- B. Temporal bone fractures
- C. Otitis externa
- D. Vascular conditions
Correct Answer: D
Rationale: Vascular conditions impair blood supply to the cochlea, causing sensorineural hearing loss.