The practical nurse (PN) is monitoring a client who was admitted following a motor vehicle collision (MVC). The PN is unable to auscultate breath sounds on the left side, and the healthcare provider is notified. While awaiting the arrival of the healthcare provider, which action should the PN take?

Demonstrate the use of an incentive spirometer.

Monitor the client for increasing respiratory distress.

Administer a PRN dose of a diuretic medication.

Encourage the client to use pursed-lip breathing.

Answer and Explanation

The Correct Answer is B

Choice A reason: Demonstrating the use of an incentive spirometer is a valuable intervention for encouraging deep breathing and preventing atelectasis. However, in the context of a client with absent breath sounds on one side, the priority is to monitor for signs of respiratory distress or complications such as a pneumothorax. While using an incentive spirometer may be beneficial in other scenarios, it is not the immediate priority in this case.
Choice B reason: Monitoring the client for increasing respiratory distress is the most critical action to take. The absence of breath sounds on the left side could indicate a serious complication such as a pneumothorax, hemothorax, or other issues that can compromise respiratory function. By closely monitoring the client, the practical nurse can detect signs of worsening condition, such as increased work of breathing, cyanosis, or changes in vital signs, and provide timely intervention or support while awaiting the healthcare provider's arrival.
Choice C reason: Administering a PRN dose of a diuretic medication is not appropriate in this context. Diuretics are used to manage fluid balance and treat conditions such as heart failure or hypertension but are not relevant for addressing the immediate concern of absent breath sounds and potential respiratory distress. The focus should remain on monitoring the client's respiratory status and ensuring appropriate interventions are available if needed.
Choice D reason: Encouraging the client to use pursed-lip breathing can be beneficial for clients experiencing shortness of breath or for managing chronic obstructive pulmonary disease (COPD). However, in the case of absent breath sounds on one side, it is more important to monitor for signs of respiratory compromise and ensure the client receives prompt medical evaluation and intervention. Pursed-lip breathing is not the immediate priority in this scenario.

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Correct Answer is C

Explanation

Choice A reason: Placing the food and utensils in the client's left visual field and leaving him alone does not address the underlying issue of the visual field deficit. While it may temporarily solve the problem of the client eating only the food on the left side, it does not encourage the client to adapt to or compensate for the right homonymous hemianopsia. The goal of rehabilitation is to help the client develop strategies to manage their condition independently, and this approach does not foster such skills.
Choice B reason: Feeding the client foods that are on the right side of his visual field is not the most effective approach, as it does not promote the client's independence or help them adapt to their visual field deficit. While it ensures the client consumes the food on the right side, it does not teach the client to compensate for their hemianopsia, which is an essential aspect of their rehabilitation.
Choice C reason: Reminding the client to look all over the tray to view and eat all the foods provided is the best approach. This action helps the client become more aware of their visual field deficit and encourages them to develop the habit of scanning their environment. Teaching the client to consistently look around their entire visual field promotes independence and helps them adapt to daily activities despite their condition. This strategy supports the goal of rehabilitation, which is to enhance the client's ability to manage their visual impairment independently.
Choice D reason: Prompting the client to rotate his plate to see foods on the right side of the tray is a practical solution, but it does not address the broader need for the client to learn to scan their environment. While rotating the plate may temporarily help the client access the food on the right side, it does not encourage the development of compensatory strategies for the visual field deficit. Encouraging the client to look all over the tray is a more effective approach for long-term adaptation and independence.

A. Initiate contact isolation precautions. B. Explain the need to keep the affected areas dry. C. Prepare the client for allergen testing. D. Review stress reduction strategies with the client.

Correct Answer is D

Explanation

Choice A reason: Initiating contact isolation precautions is not necessary for psoriasis. Psoriasis is a non-infectious and non-contagious chronic skin condition, so isolating the client would not be appropriate. The main focus should be on managing the symptoms and providing the client with strategies to alleviate their discomfort and improve their quality of life.
Choice B reason: Explaining the need to keep the affected areas dry is not suitable for managing psoriasis. In fact, keeping the skin hydrated is crucial in managing psoriasis symptoms. Dry skin can exacerbate the condition, leading to increased flaking, itching, and discomfort. The practical nurse should educate the client on proper skin care, including using moisturizers to keep the skin hydrated and avoiding harsh soaps and hot water.
Choice C reason: Preparing the client for allergen testing is not relevant in the context of psoriasis. Psoriasis is an autoimmune condition, not an allergic reaction, so allergen testing would not provide useful information for managing the condition. The focus should be on identifying and managing triggers that can exacerbate psoriasis, such as stress, infections, and certain medications.
Choice D reason: Reviewing stress reduction strategies with the client is the most appropriate action. Stress is a known trigger for psoriasis flare-ups, and helping the client develop effective stress management techniques can significantly improve their symptoms. Techniques such as mindfulness, relaxation exercises, and counseling can be beneficial in reducing stress and minimizing psoriasis symptoms. Educating the client on the importance of stress management and providing them with practical strategies can empower them to better manage their condition.

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The practical nurse (PN) is monitoring a client who was admitted following a motor vehicle collision (MVC). The PN is unable to auscultate breath sounds on the left side, and the healthcare provider is notified. While awaiting the arrival of the healthcare provider, which action should the PN take?

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A client with psoriasis reports an increase in symptoms. Which action should the practical nurse (PN) implement?

Correct Answer is D

Explanation

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