Nokea
You are taking histories from several clients who report vertigo. Which client report concerns you the most?
- A. Vertigo with hearing loss
- B. Episodic vertigo
- C. Vertigo without hearing loss
- D. Merry-go-round' vertigo
Correct Answer: A
Rationale: Vertigo accompanied by hearing loss may indicate Meniere's disease or other serious inner ear disorders requiring prompt evaluation.
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A client presents with shortness of breath, pain in the lung area, and a recent history of starting birth control pills and smoking. Vital signs include a heart rate of 110/min, respiratory rate of 40/min, and blood pressure of 140/80 mm Hg. Arterial blood gases reveal pH 7.50, PaCO2 29 mm Hg, PaO2 60 mm Hg, HCO3 20 mEq/L, and SaO2 86%. What is the priority nursing intervention?
- A. Prepare for mechanical ventilation.
- B. Administer oxygen via face mask.
- C. Prepare to administer a sedative.
- D. Assess for indications of pulmonary embolism.
Correct Answer: B
Rationale: The correct answer is B: Administer oxygen via face mask. Given the client's symptoms and ABG results showing respiratory alkalosis and hypoxemia, the priority is to improve oxygenation. Administering oxygen via face mask will help increase the oxygenation levels and alleviate the hypoxemia. Mechanical ventilation (A) is not indicated as the client is able to maintain their own ventilation. Administering a sedative (C) is not appropriate without addressing the underlying respiratory issue. Assessing for pulmonary embolism (D) may be important but not the immediate priority in this case.
Which adaptations for performing the examination would be appropriate for the patient (select all that apply)?
- A. Make sure that a family member is with him.
- B. Handle the skin with care because of potential fragility.
- C. Keep the patient warm and comfortable during the assessment.
- D. Allow the patient to watch TV to distract him from any painful assessments.
Correct Answer: C
Rationale: The correct answers are 'Handle the skin with care because of potential fragility,' 'Keep the patient warm and comfortable during the assessment,' and 'Place the patient in a position of comfort and avoid unnecessary changes in position.' These adaptations address age-related vulnerabilities and promote patient cooperation.
Symptoms indicative of cervical cancer include:
- A. Irregular vaginal bleeding
- B. Bloating
- C. Weight gain and nausea
- D. Dyspareunia
Correct Answer: A
Rationale: Irregular vaginal bleeding is a hallmark symptom of cervical cancer, often occurring between periods or after intercourse.
Anne asks how a chest x-ray would help the physician examine her heart. You respond by saying
- A. A chest x-ray is used to rule out that a fractured rib caused your pain.
- B. The chest x-ray is an error. I will cancel the order.
- C. A chest x-ray is used to detect the size and position of the heart.
- D. All patients who are admitted must have a chest x-ray.
Correct Answer: C
Rationale: Chest x-rays provide information about heart size and position.
Nursing diagnoses mostly differ from medical diagnoses, in that they are
- A. dependent upon medical diagnoses for the direction of appropriate interventions.
- B. primarily concerned with caring, while medical diagnoses are primarily concerned with curing.
- C. primarily concerned with human response, while medical diagnoses are primarily concerned with pathology.
- D. primarily concerned with psychosocial parameters, while medical diagnoses are primarily concerned with physiologic parameters.
Correct Answer: C
Rationale: Nursing diagnoses focus on the patient's response to health conditions, whereas medical diagnoses focus on the disease itself.