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1. Which pathology is associated with an asthma condition?
- A. Chronic dilation and inflammation of the bronchi.
- B. Recurrent spasms of the airways accompanied by edema and mucus production.
- C. Progressive loss of lung function due to destruction of alveolar walls.
- D. Infection of the lung parenchyma.
Correct answer: B
Rationale: The correct answer is B: Recurrent spasms of the airways accompanied by edema and mucus production. Asthma is characterized by bronchospasms, inflammation, swelling of the airways, and increased mucus production. This leads to airway constriction, making it difficult to breathe. Choices A, C, and D do not represent the typical pathology seen in asthma. Chronic dilation and inflammation of the bronchi (Choice A) is more characteristic of bronchiectasis, progressive loss of lung function due to destruction of alveolar walls (Choice C) is seen in conditions like emphysema, and infection of the lung parenchyma (Choice D) is more related to conditions like pneumonia.
2. A male client with Herpes Zoster (shingles) on his thorax tells the nurse that he is having difficulty sleeping. What is the etiology of this problem?
- A. Pain
- B. Nocturia
- C. Dyspnea
- D. Frequent cough
Correct answer: A
Rationale: The correct answer is A: Pain. The pain caused by Herpes Zoster (shingles) can disrupt sleep patterns. It is a common symptom of shingles and can lead to difficulty falling asleep or staying asleep. Nocturia (B), dyspnea (C), and frequent cough (D) are not typically associated with shingles and would not directly cause difficulty sleeping in this scenario.
3. The nurse is providing discharge teaching for a client with heart failure. Which instruction should be included to prevent fluid overload?
- A. Weigh yourself daily and report a gain of 2 pounds in 24 hours
- B. Increase fluid intake to stay hydrated
- C. Consume a high-sodium diet to retain fluids
- D. Engage in vigorous exercise daily
Correct answer: A
Rationale: The correct answer is A: 'Weigh yourself daily and report a gain of 2 pounds in 24 hours.' Daily weight monitoring is crucial for detecting fluid retention early in clients with heart failure. Reporting a gain of 2 pounds in 24 hours can indicate fluid overload, prompting timely intervention. Choice B is incorrect because increasing fluid intake can exacerbate fluid overload in clients with heart failure. Choice C is incorrect as a high-sodium diet can worsen fluid retention. Choice D is incorrect as vigorous exercise can strain the heart and worsen heart failure symptoms.
4. How should the nurse measure urinary output for an infant with dehydration?
- A. Attaching a urine collecting bag
- B. Wringing out the diaper
- C. Weighing the diaper
- D. Inserting a catheter
Correct answer: C
Rationale: The correct way to measure urinary output for an infant with dehydration is by weighing the diaper. Wet diapers are weighed to assess the amount of output accurately. Attaching a urine collecting bag and inserting a catheter are invasive methods not typically used for routine measurement of urinary output in infants. Wringing out the diaper can lead to inaccurate measurements and is not a recommended method for assessing urinary output.
5. What should the nurse assess in an infant who has been diagnosed with hypertrophic pyloric stenosis?
- A. A history of diarrhea following each feeding
- B. Gastric pain evidenced by vigorous crying
- C. Poor appetite due to a poor sucking reflex
- D. An olive-shaped mass right of the midline
Correct answer: D
Rationale: The correct answer is D. In hypertrophic pyloric stenosis, a key assessment finding is an olive-shaped mass in the right upper quadrant of the abdomen, to the right of the midline. This mass is palpable and represents the hypertrophied pyloric muscle. Choices A, B, and C are incorrect because although they may be present in infants with feeding problems, the definitive assessment for hypertrophic pyloric stenosis is the presence of an olive-shaped mass on the right side of the abdomen, not a history of diarrhea, gastric pain, or poor appetite.
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