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Which of the ff finding would confirm that a female client has mastitis? Choose all that apply
- A. A crack in the nipple or the areola
- B. Multiple lumps within the breast tissue
- C. Swollen, firm, and hard breasts
- D. Enlargement of the axillary lymph nodes
Correct Answer: C
Rationale: Mastitis is an inflammatory condition of the breast tissue, often caused by an infection. Common symptoms of mastitis in a female client include swollen, firm, and hard breasts. These changes in breast tissue texture are indicative of inflammation and infection. Other possible signs of mastitis may include redness, warmth, and tenderness in the affected breast. The presence of swollen, firm, and hard breasts would confirm the diagnosis of mastitis in a female client.
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When performing a physical examination on an infant, the nurse in charge notes abnormally low- set ears. This finding is associated with:
- A. Otogenous tetanus
- B. Tracheoesophageal fistula
- C. Congenital heart defects
- D. Renal anomalies
Correct Answer: C
Rationale: Abnormally low-set ears are often associated with certain congenital anomalies, including congenital heart defects. When a nurse notes this finding during a physical examination of an infant, it is important to consider the possibility of congenital anomalies and further assessment for associated conditions. Low-set ears alone are not diagnostic of a specific congenital heart defect, but they can serve as a clue to support the need for further evaluation to rule out any underlying cardiac issues. Other congenital anomalies that may be associated with low-set ears include renal anomalies, which makes option D a distractor in this case.
The BEST statement describing the implication of a 6-month-old boy 'transferring object to hand' is
- A. visuomotor coordination
- B. comparison ability
- C. voluntary release of objects
- D. increasing autonomy
Correct Answer: A
Rationale: Transferring objects between hands indicates developing visuomotor coordination.
A young male client visits a nurse with a complaint of chronic tension headaches. Which of the ff is the most appropriate nursing instruction to manage the client?
- A. Instructing the client to monitor for signs of bruising or bleeding
- B. Suggesting eating and swallowing techniques that reduce the potential for aspiration
- C. Counselling on alternate therapies
- D. Advising the client to change sleeping positions frequently
Correct Answer: C
Rationale: The most appropriate nursing instruction to manage a young male client with chronic tension headaches is counseling on alternate therapies. Chronic tension headaches can be caused or exacerbated by various factors such as stress, poor posture, eyestrain, or muscular tension. Counseling on alternate therapies can include techniques such as relaxation exercises, stress management strategies, mindfulness practices, physical therapy, or massage therapy. These alternative therapies can help the client manage stress, improve posture, and reduce muscle tension, which may help alleviate the frequency or intensity of tension headaches. It is important to explore non-pharmacological approaches before considering medication, especially for chronic conditions like tension headaches.
A newborn begins to cough, choke, and becomes cyanotic while feeding. What is the nurse's immediate action?
- A. Inform the physician.
- B. Have the mother stop feeding and observe.
- C. Remove the infant from the mother, place the infant in the crib for assessment, obtain oxygen saturation, and administer blow-by oxygen immediately.
- D. Continue feeding while monitoring.
Correct Answer: C
Rationale: Immediate removal from the feeding situation and rapid assessment with oxygen support is critical for airway safety.
The major pharmacologic action of albuterol sulfate (Proventil HFA) is:
- A. decreasing airway reactivity.
- B. decreasing inflammation and airway obstruction.
- C. improving the action of cilia to sweep trapped mucous upward.
- D. relaxing constricted bronchial smooth muscle.
Correct Answer: D
Rationale: Albuterol acts as a beta-2 agonist, relaxing bronchial smooth muscle to relieve airway constriction.