The practical nurse (PN) is assigned to care for a client who underwent fixation of a mandible fracture. Upon entering the client's room, the PN should confirm the presence of which item(s) in the client's room? Select all that apply.

Suction equipment.

Crash cart.

Non-rebreather mask.

Nasogastric tube.

Wire cutters.

Answer and Explanation

Correct Answer : A,E

Choice A reason: Suction equipment is essential for a client who has undergone fixation of a mandible fracture. Due to the nature of the surgery and the presence of wiring, the client may have difficulty managing oral secretions. Suction equipment ensures that any secretions can be promptly and effectively removed, preventing aspiration and maintaining a clear airway. This equipment is vital for managing the client's immediate postoperative needs and ensuring their safety.
Choice B reason: A crash cart, while critical in emergency situations, is not specifically required to be present in the client's room following mandible fracture fixation. Crash carts are typically available on the unit and can be quickly brought to the room if needed. The practical nurse should be familiar with the location of the crash cart and how to access it, but it does not need to be permanently stationed in the client's room.
Choice C reason: A non-rebreather mask is used to deliver high concentrations of oxygen to clients experiencing severe respiratory distress or hypoxemia. While it is an important piece of equipment for respiratory emergencies, it is not specifically necessary to have in the room of a client with a mandible fracture fixation. The priority is to have suction equipment and wire cutters immediately available, while other oxygen delivery devices can be accessed as needed.
Choice D reason: A nasogastric tube is used for decompression of the stomach or for feeding clients who are unable to take oral nutrition. It is not specifically required for a client with a mandible fracture fixation unless there are additional complications or indications for its use. The practical nurse should focus on equipment directly related to managing the fixation and maintaining the client's airway.
Choice E reason: Wire cutters are a critical item to have in the room of a client with a mandible fracture fixation. In the event of an emergency, such as vomiting or respiratory distress, the wires securing the mandible may need to be quickly cut to ensure the client's airway is not compromised. Having wire cutters immediately available ensures that the practical nurse can respond swiftly and effectively to any urgent situations, maintaining the client's safety and airway patency.

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Correct Answer is B

Explanation

Choice A reason: Aldosterone is a hormone produced by the adrenal cortex that helps regulate sodium and potassium levels in the body. While aldosterone levels can indicate adrenal function, they are not as commonly used as cortisol levels in diagnosing adrenal cortex failure. Aldosterone regulation is also influenced by the renin-angiotensin-aldosterone system, making it a less direct indicator of overall adrenal cortex function compared to cortisol.
Choice B reason: Cortisol is a glucocorticoid hormone produced by the adrenal cortex and plays a vital role in regulating metabolism, immune response, and stress. Measuring cortisol levels is a primary method for assessing adrenal cortex function. Low cortisol levels can indicate adrenal insufficiency or failure, such as in conditions like Addison's disease. Evaluating cortisol levels provides a direct assessment of the adrenal gland’s ability to produce essential hormones necessary for the body's normal functioning.
Choice C reason: Thyroxine (T4) is a hormone produced by the thyroid gland, not the adrenal cortex. It plays a crucial role in regulating metabolism, growth, and development. While thyroxine levels are important for thyroid function assessment, they do not directly reflect the functioning of the adrenal gland. Therefore, thyroxine levels are not relevant in diagnosing adrenal cortex failure.
Choice D reason: Insulin is a hormone produced by the pancreas and is essential for regulating blood glucose levels. It is not related to the adrenal cortex. Monitoring insulin levels is important for diagnosing and managing diabetes mellitus but does not provide information about the functioning of the adrenal gland. Insulin levels are not used to assess adrenal cortex function.

A. Palpating the client's neck gently. B. Measuring the client's vital signs. C. Compressing the client's pretibial area. D. Observing the client's face and eyes.

Correct Answer is D

Explanation

Choice A reason: Palpating the client's neck gently is important in assessing thyroid function, as it can help detect the presence of thyroid enlargement or nodules. However, this action does not confirm the presence of exophthalmos, which is characterized by the protrusion of the eyeballs. Neck palpation is useful for evaluating thyroid size and consistency but does not provide information about eye-related symptoms.
Choice B reason: Measuring the client's vital signs, including heart rate, blood pressure, and temperature, is essential in monitoring the overall health and metabolic status of a client with hyperthyroidism. Hyperthyroidism can lead to increased heart rate, elevated blood pressure, and other systemic effects. However, measuring vital signs does not confirm the presence of exophthalmos. While vital signs provide important information about the client's condition, they do not address specific eye symptoms.
Choice C reason: Compressing the client's pretibial area is typically performed to assess for pretibial myxedema, which is another possible manifestation of hyperthyroidism, particularly in Graves' disease. Pretibial myxedema is characterized by thickening and swelling of the skin on the lower legs. However, this action does not confirm the presence of exophthalmos. It is important to assess for both pretibial myxedema and exophthalmos in clients with hyperthyroidism, but they require different examination techniques.
Choice D reason: Observing the client's face and eyes is the correct action to confirm the presence of exophthalmos. Exophthalmos is the abnormal protrusion of the eyeballs and is a common feature of Graves' disease, a type of hyperthyroidism. By carefully examining the client's face and eyes, the practical nurse can look for signs of eye protrusion, lid retraction, and other related symptoms. This focused assessment helps in identifying exophthalmos and determining the extent of the condition, which is essential for appropriate management and treatment.

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The practical nurse (PN) is assigned to care for a client who underwent fixation of a mandible fracture. Upon entering the client's room, the PN should confirm the presence of which item(s) in the client's room? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The practical nurse (PN) is providing care for a client suspected of adrenal cortex failure. Which laboratory value would indicate the functioning of the adrenal gland?

Correct Answer is B

Explanation

The practical nurse (PN) is performing a focused assessment on a client with hyperthyroidism. To confirm the presence of exophthalmos, which action should the PN include in the assessment?

Correct Answer is D

Explanation

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