A patient arrives in the emergency room with an attack of acute bronchiectasis. The nurse knows that the principle pathologic finding in the diagnosis of bronchiectasis includes what?
A) Increase in the red blood cell concentration in the blood
B) Leakage of fluid into the alveolar interstitial spaces
C) Chronic, irreversible dilation of the bronchi and bronchioles
D) Obstruction of the pulmonary vasculature by a clot
Ans: C
Feedback: The principle pathological finding in bronchiectasis patients is chronic, irreversible dilation of the bronchi and bronchioles. Polycythemia is an increase in the red blood cell concentration in the blood. This occurs in COPD as the body attempts to improve oxygen-carrying capacity. In acute respiratory distress syndrome (ARDS), there is leakage of fluid into the alveolar interstitial spaces. Pulmonary embolism is an obstruction of the pulmonary vasculature by a clot.
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A student nurse is caring for a 72-year-old client admitted to the hospital with pneumonia. The client asks what steps he can implement to stay healthier in the future. Which would be the most appropriate response by the student nurse?
A) "You can start by taking a multivitamin on a daily basis." B) "At your age, most of the damage has already been done to your immune system, so there is not much you can do." C) "Elderly clients are at greatest risk for pneumonia, so you should get a pneumonia vaccination every year." D) "You should drink a yogurt drink that is supplemented with L. Casei immunitas cultures on a daily basis."
The nurse is helping the spouse of a client who just passed away. Which of the following is considered a normal uncomplicated grief reaction?
a. Numbness c. Talkativeness b. Laughter d. Hunger
Which technique should a nurse use in performing the Rinne tuning fork test?
A. Start the fork vibrating and place the stem on the mastoid process. When the client no longer feels the vibration, move it in front of the pinna and ask the client to indicate when sound is no longer heard. B. Start the fork vibrating and place the stem on the mastoid process. When the client no longer hears sound, move it in front of the pinna and ask the client to indicate when sound is no longer heard. C. Start the fork vibrating, hold the fork in front of the pinna, and ask the client to indicate when sound is no longer heard. Then place the stem on the mastoid process and ask the client to indicate when he or she no longer feels the vibration. D. Start the fork vibrating, hold the fork in front of the pinna, and ask the client to indicate when sound is no longer heard. Then place the stem on the mastoid process and ask the client to indicate when he or she no longer hears the sound.
When teaching family members how to care for an ill member, upon which person will the nurse typically concentrate teaching?
A. Teach the family member with the most strength and competence to do what must be done to ensure that it gets done. B. Teach the ill member what must be done because he/she is responsible for his/her own care. C. Teach the weakest family member what must be done because that will strengthen his/her position in the family. D. Teach the wife/mother what must be done because caring for others is a female role and expectation.