A nurse educator is presenting at a continuing education seminar for nurses. As part of his presentation, he is emphasizing the prevention of skin breakdown in immobile patients who have suffered from a stroke. The level of prevention being discussed by the nurse educator is:

Educational Prevention

Tertiary Prevention

Secondary Prevention

Primary Prevention

Answer and Explanation

The Correct Answer is B

Choice a reason:
Educational Prevention is not a recognized level of prevention in healthcare. While education is a key component in all levels of prevention, it is not a standalone category. Education is typically included in primary prevention as it involves informing the public about health practices to prevent the onset of disease.

Choice b reason:
Tertiary Prevention is the level of prevention that aims to manage and treat an existing disease to prevent further complications or deterioration. In the case of immobile stroke patients, tertiary prevention would involve measures to prevent skin breakdown and other complications associated with immobility and the stroke's long-term effects.

Choice c reason:
Secondary Prevention involves early detection and prompt intervention to prevent the progression of a disease. For stroke patients, secondary prevention might include monitoring for signs of skin breakdown so that early treatment can be initiated. However, the scenario described focuses on managing an existing condition rather than early detection.

Choice d reason:
Primary Prevention aims to prevent the disease or injury before it occurs. This would involve strategies to prevent strokes in the first place, such as controlling high blood pressure or encouraging healthy lifestyle changes. It does not directly relate to the prevention of skin breakdown in patients who have already had a stroke.

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Correct Answer is A

Explanation

Choice a reason:
Resonance is the expected percussion note when percussing over normal, healthy lung tissue. This sound is produced due to the presence of air in the lung parenchyma, which allows for the transmission of sound waves through the air-filled spaces. In a healthy individual, the resonance indicates that the lungs are free from any significant abnormalities that could alter the sound, such as fluid or solid masses.
Choice b reason:
Tympanic notes are typically heard over hollow, air-containing structures like the stomach. This sound is not expected in lung percussion unless there is a large, air-filled cavity within the lung tissue, which would be abnormal and indicative of a pathological condition such as a pneumothorax.
Choice c reason:
A flat percussion note is usually heard over dense tissues where air is not present, such as over the thigh muscles or areas of the chest where lung tissue has been replaced by something more solid, like in the case of a pleural effusion or a lung mass.
Choice d reason:
Dullness on percussion usually indicates that the lung is not air-filled and may be suggestive of underlying conditions such as pneumonia, tumor, or atelectasis. It is a higher-pitched sound compared to flatness and is typically found in areas of the lung that are filled with fluid or solid tissue rather than air.

A. Oral mucosa B. Ear lobes C. Soles of the feet D. Conjunctivae

Correct Answer is A

Explanation

Choice a reason:
The oral mucosa is the most reliable area to evaluate for central cyanosis in a client with asthma. Central cyanosis reflects a decrease in arterial oxygenation and is best assessed where the blood flow is high and the skin is thin, which is the case with the oral mucosa. It is less likely to be affected by peripheral factors such as temperature and is therefore a more accurate indicator of oxygen saturation in the central circulation.

Choice b reason:
While ear lobes can show signs of cyanosis, they are not the most reliable indicator of central cyanosis because they are more prone to peripheral cyanosis. Peripheral cyanosis can occur in the ear lobes due to local vasoconstriction or decreased blood flow, which may not reflect central oxygenation levels.

Choice c reason:
The soles of the feet are not a reliable indicator of central cyanosis, especially in a client with asthma. The skin on the soles is thicker and has less blood flow compared to the oral mucosa, making it a poor site for assessing central cyanosis. Additionally, the soles can be affected by peripheral factors like pressure and temperature.

Choice d reason:
Conjunctivae are not the most reliable indicator of central cyanosis. While they can show signs of cyanosis, the assessment can be affected by environmental factors and the presence of blood vessels in the conjunctiva that may not accurately reflect central oxygenation levels.

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A nurse educator is presenting at a continuing education seminar for nurses. As part of his presentation, he is emphasizing the prevention of skin breakdown in immobile patients who have suffered from a stroke. The level of prevention being discussed by the nurse educator is:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is performing a respiratory physical examination on a healthy patient. When performing the percussion physical assessment technique, the lung percussion note should be:

Correct Answer is A

Explanation

A nurse is assessing a client who has asthma. Which of the following areas should the nurse evaluate as the most reliable indicator of central cyanosis?

Correct Answer is A

Explanation

When planning care for a client with an inner ear infection, the nurse will need to include interventions for which of the following potential problems?

A nurse prepares an educational session on the importance of oral hygiene. Which teaching tip should be included in the section about preventing gingivitis?

A nurse is performing a respiratory system physical examination. To assess the resonance of voice sounds heard during auscultation of the lungs, the nurse instructs the patient to say "ee," and if the sound is heard as "ay," this is known as:

The nurse working in an ophthalmology clinic is preparing to assess a patient's near vision. Which piece of equipment would the nurse use for this assessment?

While conducting the health assessment, the nurse instructs the client about secondary prevention activities. What information did the nurse most likely provide to this client?

When conducting a physical examination of a client with generalized muscle weakness, which of the following is the PRIORITY for the nurse?

The nurse is preparing to auscultate the lung sounds of a young adult. Which sound will the nurse expect to hear over most of the client's lungs?

In which disease process should a nurse expect to see a patient with the presence of pitting edema?