When a patient is diagnosed to have pneumonia, the breath sounds detected by the nurse on auscultation of the affected area would be ______.

Correct Answer: B

Rationale: When a patient is diagnosed with pneumonia, the breath sounds detected by the nurse on auscultation of the affected area would typically include fine crackles. Fine crackles are discontinuous, high-pitched crackling or rattling sounds heard during inspiration that indicate the presence of fluid in the small airways or alveoli. These crackles are caused by the movement of secretions or exudate within the bronchioles or alveoli, which is a common characteristic of pneumonia. Wheezing sounds are usually associated with conditions such as asthma, bronchitis, or COPD and are caused by narrowed airways. Stridor is a high-pitched, crowing sound that typically indicates an obstruction in the upper airway and is often heard in cases of laryngeal inflammation or foreign body aspiration. Deep and low-pitched breath sounds are more characteristic of conditions like chronic bronchitis.

Correct Answer: D

Rationale: Acute respiratory distress syndrome (ARDS) is a severe condition characterized by widespread inflammation in the lungs leading to increased pulmonary vascular permeability, non-cardiogenic pulmonary edema, and respiratory failure. In ARDS, the alveolar-capillary barrier is disrupted, resulting in fluid accumulation in the alveoli and impaired gas exchange.

Correct Answer: D

Rationale: Arterial blood gases (ABGs) do not directly assess the client's electrolyte and fluid balance. ABGs primarily evaluate the client's acid-base balance and oxygenation status by measuring levels of pH, partial pressure of carbon dioxide (PCO2), and bicarbonate (HCO3) in the arterial blood. While ABGs can provide some information about blood parameters, such as oxygen saturation, they do not comprehensively assess electrolyte levels or fluid balance. To specifically assess electrolytes and fluid balance, additional tests like basic metabolic panels or comprehensive metabolic panels would be required.

Correct Answer: B

Rationale: A priority intervention for a client with multiple myeloma is to include coughing and deep breathing exercises in the plan of care. Multiple myeloma can affect the bone marrow's ability to produce healthy blood cells, including red blood cells, which can lead to anemia. Anemia can cause fatigue and shortness of breath. By encouraging coughing and deep breathing exercises, the nurse can help improve lung function, enhance oxygenation, and prevent potential respiratory complications in the client with multiple myeloma. This intervention is crucial in promoting respiratory health and overall well-being for the client.

Correct Answer: B

Rationale: In Stage I of Hodgkin's disease, the most commonly seen early symptom is usually unexplained fever and night sweats. Other common symptoms at this stage may include unexplained weight loss, itching, and enlarged lymph nodes in the neck, underarms, or groin. Chest and back pains, subnormal body temperature, and swelling of extremities are not typically early indicators of Stage I Hodgkin's disease.

Correct Answer: C

Rationale: Osteoarthritis in the hip joint can lead to weakness or dysfunction in the hip abductor muscles, causing a Trendelenburg gait. This gait abnormality is characterized by a dropping of the pelvis on the opposite side of the affected hip during weight-bearing on the affected leg. It is a common clinical manifestation of hip osteoarthritis due to the muscle weakness and altered mechanics in the hip joint. Baker's cyst is associated with knee osteoarthritis, Heberden's nodes are commonly seen in osteoarthritis of the fingers, and Swan-neck deformity is typically seen in rheumatoid arthritis, not osteoarthritis.

Correct Answer: B

Rationale: In the given situation, the nursing diagnosis that is NOT RELEVANT to sexual health is option B, Health-seeking behaviors related to reproductive functioning. This diagnosis focuses on the patient's proactive approach to seeking healthcare services related to reproductive health matters. However, in the situation presented of a pregnant patient with sickle cell anemia experiencing fever, painful swelling, and in labor pain, the immediate priority lies in addressing the health issues related to sickle cell disease and the current pregnancy. Sexual health is not the primary concern in this scenario compared to managing the complications of sickle cell anemia during pregnancy. Therefore, the diagnosis related to health-seeking behaviors related to reproductive functioning is not as pertinent in this specific case.

Correct Answer: C

Rationale: Nurse Cora should consider statement C as TRUE with anorexia nervosa. Cultures that portray thinness as the ideal standard of beauty can increase the risk of developing anorexia nervosa. This is because individuals may internalize these societal norms and feel pressure to attain the thin ideal, leading to disordered eating behaviors.

Correct Answer: B

Rationale: In a stratified sampling method, the population is divided into subgroups or strata based on certain characteristics that are relevant to the research objective. This allows for representation from each subgroup in the sample, ensuring that different segments of the population are taken into account.