Which of the following assessment findings indicates an emergency and the need for immediate action on the part of the nurse?

Clubbing of the fingernails

Tracheal deviation

Contraction of the diaphragm

Auscultation of rhonchi throughout the lungs

Answer and Explanation

The Correct Answer is B

A. Clubbing of the fingernails is typically a sign of chronic hypoxia and is seen in conditions like cystic fibrosis, COPD, and other respiratory or cardiovascular diseases. It is a long-term issue and does not indicate an immediate emergency.
B. Tracheal deviation is a medical emergency and typically indicates tension pneumothorax, where air accumulates in the pleural space, shifting the trachea away from the affected side. This can compress the heart and lungs, leading to respiratory and circulatory collapse, requiring immediate action.
C. Contraction of the diaphragm may refer to normal breathing mechanics and does not indicate an immediate emergency unless it is associated with respiratory distress or failure.
D. Rhonchi are abnormal lung sounds often associated with mucus in the airways and can be heard in conditions like bronchitis or COPD. Although they may require attention, they do not represent an immediate emergency compared to tracheal deviation.

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Correct Answer is B

Explanation

A. 4 oz diet soda: This is incorrect. Diet soda contains no sugar and will not raise the client's blood glucose level. Although it may provide some hydration, it won't address the hypoglycemia.
B. 4 oz skim milk: This is the correct choice. Skim milk contains both lactose (a sugar) and protein, which can help raise the blood glucose and stabilize it over a longer period. This is a suitable option for treating mild hypoglycemia.
C. Graham crackers: While graham crackers contain carbohydrates, they are not the most immediate or efficient choice in this case. They are slower to digest and may not raise the blood glucose level as quickly as the combination of sugar and protein found in milk.
D. 1 tsp sugar: This is not the best option. While sugar can raise blood glucose, it is a fast-acting form of carbohydrate that may not sustain the client's blood glucose for a longer period. A more balanced option, such as milk, would provide both rapid and sustained glucose elevation.

A. Blistering burns B. Diarrhea C. Dry mouth D. Nausea

Correct Answer is C

Explanation

A. Blistering burns are not a typical side effect of radiation therapy for laryngeal cancer. Radiation burns can occur on the skin, but they are more likely to cause irritation and redness rather than blistering burns, especially in the case of internal radiation targeting the larynx.
B. Diarrhea is a common side effect of radiation therapy when the abdominal or pelvic areas are treated, but it is not typically associated with radiation therapy to the larynx.
C. Dry mouth (xerostomia) is a common side effect of radiation therapy for laryngeal cancer, as the salivary glands may be affected by the radiation. This results in reduced saliva production, leading to a dry mouth.
D. Nausea is not a typical side effect of radiation therapy for laryngeal cancer specifically, though it may occur if other areas (such as the stomach) are being treated. Nausea is more commonly associated with chemotherapy.

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Which of the following assessment findings indicates an emergency and the need for immediate action on the part of the nurse?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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