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Which of the ff does the examiner note when auscultating the lungs of a client with pleural effusion?
- A. Pronounced breath sounds
- B. Expiratory wheezes
- C. Friction rub
- D. Fluid in the involved area
Correct Answer: D
Rationale: When auscultating the lungs of a client with pleural effusion, the examiner would note sounds consistent with fluid accumulation in the pleural space. This includes decreased or absent breath sounds over the area where the effusion is present. The presence of fluid in the involved area may cause a dullness to percussion as well. Pronounced breath sounds and expiratory wheezes are not typically associated with pleural effusion. While a friction rub may be heard in conditions such as pleurisy, it is not specific to pleural effusion.
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Which of the following is the humoral immune response?
- A. B cells phagocytise the foreign antigen
- B. T cells are stimulated by B cells and turn into plasma cells, which produce antibodies or memory cells.
- C. B cells are stimulated by T helper cells or macrophages and turn into plasma cells, which produce antibodies or memory cells.
- D. T cells produce antibodies.
Correct Answer: C
Rationale: The humoral immune response involves the activation of B cells, which are stimulated by T helper cells or macrophages. When B cells are activated, they differentiate into plasma cells that produce antibodies specific to the foreign antigen. These antibodies can neutralize pathogens, tag them for destruction by other immune cells, or activate the complement system. In addition to producing antibodies, memory B cells are also generated during this process, providing long-lasting immunity upon re-exposure to the same antigen. This coordinated response is an essential part of the adaptive immune system's defense mechanism against foreign invaders.
Reggie is a teenager suffering from osteomyelitis; the nurse would expect which of the following symptoms? Select all that apply.
- A. Fever
- B. Irritability
- C. Pallor
- D. Tenderness
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A client is admitted for postoperative assessment and recovery after surgery for a kidney tumor. The nurse needs to assess for signs of urinary tract infection. Which of the ff measures can be used to help detect UTI?
- A. Encourage the client to breathe deeply and cough every 2hrs
- B. Monitor temperature every 4hrs
- C. Splint the incision when repositioning the client
- D. Irrigate tubes as ordered CARING FOR CLIENTS WITH DISORDERS OF THE BLADDER AND URETHRA
Correct Answer: B
Rationale: Monitoring temperature every 4 hours is crucial in detecting signs of a urinary tract infection in a postoperative client. An increase in temperature can indicate the presence of an infection, and early identification is essential for prompt treatment. While coughing and deep breathing (Option A) are beneficial for postoperative clients to prevent respiratory complications, they are not directly related to detecting UTI. Splinting the incision (Option C) is important for incisional care but does not specifically help in detecting UTI. Irrigating tubes (Option D) should only be done as ordered by the healthcare provider and is not a routine measure for detecting UTI.
For a client with sickle cell anemia, how does the nurse assess for jaundice?
- A. The nurse assesses mental status, verbal ability, and motor strength
- B. The nurse observes the joints for signs of swelling
- C. The nurse inspects the skin and sclera for jaundice
- D. The nurse collects a urine specimen
Correct Answer: C
Rationale: In a client with sickle cell anemia, jaundice is a common manifestation due to the breakdown of red blood cells. The nurse should inspect the skin and sclera for signs of jaundice, which presents as a yellow discoloration. This assessment helps in identifying the presence and severity of jaundice in the client, which can be indicative of ongoing hemolysis and the need for further interventions. Monitoring for jaundice is important in managing clients with sickle cell anemia to address complications early and provide appropriate care.
Which communication technique should the nurse avoid when interviewing children and their families? TestBankWorld.org
- A. Using silence
- B. Using cliche
- C. Directing the focus
- D. Defining the problem
Correct Answer: C
Rationale: When interviewing children and their families, nurses should avoid directing the focus. Directing the focus involves steering the conversation in a certain direction, which may hinder open communication and the exploration of important issues. It is essential to allow children and their families to express themselves freely and openly, which can lead to a more comprehensive understanding of their perspectives and needs. Avoiding directing the focus can help build trust and rapport with the children and their families, leading to more effective communication and care.