A client with a history of lung cancer reluctantly comes to the clinic because of persistent hoarseness and a chronic cough. The client's respirations are labored when speaking and the capillary refill is 3 seconds. Which additional finding warrants intervention by the nurse?

Coarse breath sounds.

Rust colored sputum.

Unexplained fatigue.

Clubbed fingernails.

Answer and Explanation

The Correct Answer is A

The client's history of lung cancer, persistent hoarseness, chronic cough, and labored respirations when speaking indicate potential respiratory complications. Coarse breath sounds may suggest the presence of airway obstruction or fluid accumulation in the lungs, which can be indicative of a worsening condition.

The nurse should intervene promptly by assessing the client's respiratory status further, providing appropriate respiratory support, and notifying the healthcare provider for further evaluation and intervention.

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Correct Answer is D

Explanation

This breakfast selection is the most appropriate for a 16-year-old with diarrhea. Oatmeal is a bland and easily digestible food that can help to firm up the stool. Bananas are a good source of potassium and can help replace electrolytes that may be lost through diarrhea. Herbal tea is a non-caffeinated option that can help to soothe the digestive system. It is important to avoid foods that are greasy, high in fat, or spicy, as they can worsen diarrhea symptoms.

A. Give the client a schedule of planned daily activities. B. Engage the client in a game of cards. C. Encourage the client to have lunch off the unit. D. Complete an assessment of social support.

Correct Answer is A

Explanation

A) Correct- this can help them structure their time, reduce boredom and anxiety, and increase their sense of control and achievement. This can also foster social interaction and engagement with the staff and peers. A schedule of planned daily activities is consistent with the principles of psychosocial rehabilitation, which is an evidence-based approach for people with schizophrenia.
B) Incorrect- this may be too challenging or stressful for the client, especially if they have cognitive impairments or negative symptoms.
C) Incorrect- may expose them to unfamiliar or unpredictable situations that could trigger or worsen their psychotic symptoms.
D) Incorrect- it is not an intervention that directly addresses the client's current problem of social isolation.

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A client with a history of lung cancer reluctantly comes to the clinic because of persistent hoarseness and a chronic cough. The client's respirations are labored when speaking and the capillary refill is 3 seconds. Which additional finding warrants intervention by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which breakfast selection should the nurse recommend for a 16-year-old with diarrhea?

Correct Answer is D

Explanation

A client with a diagnosis of schizophrenia sits in the day room and fails to interact with the staff or peers. Which intervention is best for the nurse to implement with this client?

Correct Answer is A

Explanation

Which instruction regarding skin care should the nurse provide to a client who is receiving radiation therapy for metastatic breast cancer?

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The nurse is administering multiple prescribed vaccines to a toddler. Which strategy should the nurse prioritize to reduce the duration of pain?

The nurse is caring for a client after a thoracentesis that drained 50 mL of clear fluid from the left lung. Which assessment finding should the nurse report to the healthcare provider immediately?

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The nurse is assessing a 4-year-old child with eczema. The child's skin is dry and scaly, and the mother reports that the child frequently scratches the lesions on the skin to the point of causing bleeding. Which guideline is indicated for care of this child?