Nokea
While assessing for costovertebral angle tenderness, a nurse percusses the area, and the client complains of sharp pain. The nurse interprets this finding as most indicative of which disorder?
- A. Liver enlargement
- B. Ovarian infection
- C. Spleen enlargement
- D. Kidney inflammation
Correct Answer: D
Rationale: When assessing for costovertebral angle tenderness, sharp pain on percussion of the area indicates inflammation of the kidney or paranephric area. The correct technique involves placing one hand over the 12th rib, at the costovertebral angle, and thumping that hand with the ulnar edge of the other fist. The client normally feels a thud and should not experience pain. Ovarian infection, liver enlargement, or spleen enlargement are not associated with the costovertebral angle tenderness. Therefore, the correct answer is kidney inflammation.
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A nurse is palpating a client's sinus areas. Which sensation does the nurse expect the client to indicate that he or she is feeling during palpation if the sinuses are normal?
- A. Firm pressure
- B. Pain behind the eyes
- C. Pain during palpation
- D. Pressure producing an acute headache
Correct Answer: A
Rationale: The correct answer is A: Firm pressure. When the sinuses are normal, the client is expected to feel firm pressure during palpation. Pain during palpation of the sinuses is indicative of acute sinusitis, not a normal finding. Pain behind the eyes and pressure producing an acute headache are symptoms of acute sinusitis, not sensations felt during sinus palpation in normal sinuses.
An adult client tells the clinic nurse that he is susceptible to middle ear infections. About which risk factor related to infection of the ears does the nurse question this client?
- A. Loud music
- B. Use of power tools
- C. Occupational noise
- D. Exposure to cigarette smoke
Correct Answer: D
Rationale: The correct answer is 'Exposure to cigarette smoke.' Otitis media (middle ear infection) is associated with various factors like colds, allergies, sore throats, and blockage of the eustachian tubes. Risk factors include exposure to cigarette smoke, youth (as otitis media is usually a childhood disease), congenital abnormalities, immune deficiencies, family history of otitis media, recent upper respiratory infections, and allergies. Choices A, B, and C (Loud music, Use of power tools, and Occupational noise) are more likely to cause hearing loss rather than being direct risk factors for middle ear infections.
When a client who is 25 years of age asks the nurse when she should seek fertility counseling, the best response by the nurse is:
- A. Fertility counseling should be sought when you have been unable to conceive after 1 year of unprotected intercourse.'
- B. Fertility counseling should be sought when you have not been able to conceive after 6-9 months of unprotected intercourse.'
- C. The average time it takes someone your age to conceive is 5-12 months, so if you haven't conceived by then, we can refer you.'
- D. We can give you some guidance now on how to increase your chances of conceiving and then refer you if it doesn't happen within a year.'
Correct Answer: D
Rationale: The guidelines for a fertility workup are to refer after the couple has not conceived after one year of unprotected intercourse. So, Choice 1 is technically correct, but it doesn't consider the immediate need for the couple to have some counseling. Choice 4 is the best answer because it gives the couple guidance now and the referral at the appropriate time. If the woman is over the age of 35, an earlier referral, at six to nine months of unprotected intercourse, is appropriate. It is true that the average time it takes a 25-year-old woman to conceive is 5.3 months, but that does not address the concern the client is expressing. Choice 4 is still the most caring and correct answer. Couples conceive within the first month of unprotected intercourse 20% of the time.
Which of these medications is least likely to cause tinnitus?
- A. Aspirin
- B. Lasix
- C. Gentamicin
- D. Fluoxetine
Correct Answer: D
Rationale: The correct answer is Fluoxetine. Among the options provided, Fluoxetine is the medication least likely to cause tinnitus. Gentamicin, Lasix, and Aspirin are known ototoxic medications that have a potential side effect of causing tinnitus, a ringing in the ear. Gentamicin is an antibiotic, Lasix is a diuretic, and Aspirin is a common pain reliever that can lead to tinnitus. In contrast, Fluoxetine is a selective serotonin reuptake inhibitor (SSRI) primarily used as an antidepressant, and it has a lower risk of causing tinnitus compared to the other options.
When a 25-year-old client complains of chest congestion and cough after previously presenting with cold symptoms, what data should the nurse collect?
- A. Data related to follow-up care
- B. A complete health database
- C. Data related to the respiratory system
- D. Data related to the treatment for the cold
Correct Answer: C
Rationale: In this case, the nurse should collect data related to the respiratory system since the client is presenting with symptoms like chest congestion and cough, indicating a respiratory issue. Focusing on the respiratory system will help gather pertinent information to assess the current problem comprehensively. A complete health database involves a detailed health history and full physical examination, which is beyond the immediate scope of the presenting issue. Data related to follow-up care is premature as the primary focus should be on assessing the current respiratory symptoms. Data related to the treatment for the cold is not the priority at this stage, as understanding the underlying respiratory problem is crucial for appropriate intervention.