A nurse assesses a patient's lungs and notes the presence of low-pitched snoring sounds that clear with coughing. What action by the nurse is best?
a. Prepare to treat the patient for asthma.
b. Prepare to treat the patient for pneumonia. c.
Teach the parent how to prevent croup.
d. Assess the patient for heart failure.
ANS: B
The patient has rhonchi. Rhonchi are caused by increased secretions in large airways and can be seen in pneumonia or in other conditions, leading to increased mucus production. The nurse prepares to treat the patient for pneumonia. Asthma would manifest with wheezing, coup with stridor, and heart failure with rales or crackles.
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When the daughter of a client diagnosed with moderate Alzheimer's disease (AD) asks about the possible benefits of enrolling her mother in art classes, the nurse's response is based on the knowledge that:
a. creative activities are not limited to cogni-tively intact older adults; even individuals with dementia can benefit from creative activities. b. individuals with dementia who have ra-tional language skills can benefit from creative activities. c. cognitively impaired elders cannot benefit from creative activities due to altered brain processes. d. cognitively impaired elders are usually too agitated to participate in creative arts.
A patient with AIDS is being prepared for discharge. The nurse caring for the patient with AIDS knows the patient receives Agenerase. What dietary counseling will the nurse provide based upon the patient's medication regimen?
A) Avoid high-fat meals while taking this medication. B) Limit fluid intake to 2 liters a day. C) Limit sodium intake to 2 grams per day. D) Avoid meals high in protein while taking this medication.
An 18-year-old female client who is sexually active asks the nurse for information on barrier contraceptives. Which of the following should the nurse say is a mechanical barrier contraceptive?
A) Vaginal foams B) Cervical cap C) Spermicidal creams D) Spermicidal jellies
The nurse is completing a mental status examination for a newly admitted patient. In which part of the nursing process is the nurse functioning?
a. Assessment b. Planning c. Implementation d. Evaluation