The nurse is performing an assessment of the client's mouth. The nurse recognizes that the tissue that connects the tongue to the floor of the mouth is the:

Frenulum

Palate

Uvula

Papillae.

Answer and Explanation

The Correct Answer is A

A. Frenulum:

The frenulum is a thin band of tissue in the mouth that connects the tongue to the floor of the mouth. It aids in the tongue's movement and flexibility during speaking and swallowing.

B. Palate:

The palate refers to the roof of the mouth. It has two parts: the hard palate (at the front, made of bone) and the soft palate (at the back, made of muscle). The palate plays a crucial role in speech and swallowing.

C. Uvula:

The uvula is a small, fleshy extension at the back of the soft palate in the mouth. It participates in various functions, including speech articulation, preventing food from entering the nasal cavity during swallowing, and producing certain sounds.

D. Papillae:

Papillae are small, raised structures on the tongue that contain taste buds. They are responsible for detecting different tastes: sweet, salty, sour, bitter, and umami (savory). Papillae give the tongue its rough texture.

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Correct Answer is D

Explanation

A. When bronchial breath sounds are auscultated in the trachea.

Auscultating bronchial breath sounds in the trachea is a normal finding, as the trachea is close to the upper airway, and this is where bronchial sounds are normally heard. However, if these sounds are heard in the peripheral lung fields, it can indicate an abnormal condition.

B. When the client is experiencing excessive sneezing from a tree pollen allergy.

Excessive sneezing due to allergies would not typically result in increased breath sounds. Allergies may cause nasal congestion, but they don't directly lead to increased breath sounds.

C. When the client is resting in bed and not experiencing respiratory issues.

If a client is at rest and not experiencing any respiratory issues, breath sounds should typically be normal. There would be no reason to expect increased breath sounds in this scenario.

D. When the bronchial tree is obstructed by secretions.

Increased breath sounds, such as wheezing or rhonchi, can be auscultated when there is an obstruction in the bronchial tree due to secretions, narrowing of the airways, or other causes. These sounds are typically abnormal and indicate an issue with air movement through the airways.

A. Increased temperature B. Increase hematocrit C. Blood pressure 180/100 D. Respiratory rate 32 E. Heart rate 120bpm

Correct Answer is ["C","D"]

Explanation

A. Increased temperature: Fluid overload typically doesn't cause an increased temperature. Infections or other inflammatory processes are more likely causes of elevated body temperature.

B. Increased hematocrit: Fluid overload usually results in dilution of blood components, leading to a decreased hematocrit (lower concentration of red blood cells in the blood). An increased hematocrit is not a typical finding in fluid overload.

C. Blood pressure 180/100: Elevated blood pressure can be associated with fluid overload, especially if the overload is chronic. This is a correct assessment finding that requires intervention and monitoring.

D. Respiratory rate 32: An increased respiratory rate can be a sign of respiratory distress, which may occur in severe cases of fluid overload, especially if it leads to pulmonary edema. This is a correct assessment finding that requires intervention and further evaluation.

E. Heart rate 120 bpm: An increased heart rate can be a compensatory mechanism in response to fluid overload, especially if the heart is trying to maintain cardiac output. However, this heart rate alone is not specific enough to confirm fluid overload. Other signs and symptoms, such as edema, increased blood pressure, and respiratory distress, are more indicative of fluid overload.

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The nurse is performing an assessment of the client's mouth. The nurse recognizes that the tissue that connects the tongue to the floor of the mouth is the:

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Naxlex Comprehensive Predictor Exams

The nurse is auscultating a client's chest for breath sounds. In which situation should the nurse expect to auscultate increased breath sounds?

Correct Answer is D

Explanation

The nurse is assessing a client diagnosed with fluid overload. The nurse should implement priority interventions for which of the following assessment findings? (Select all that apply.)

Correct Answer is ["C","D"]

Explanation

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