1.

QUIZ
2.
3. A nurse is performing a respiratory assessment on a client being treated for an asthma attack.

The nurse determines that the client’s respiratory status is worsening if which of the following

occurs?

1 Loud wheezing

2 Wheezing on expiration

3 Noticeably diminished breath sounds

4 Wheezing during inspiration and expiration

Answer: 3 Rationale: Noticeably diminished breath sounds are an indication of severe obstruction and
impending respiratory failure. Wheezing is not a reliable manifestation to determine the severity of an
asthma attack. Clients with minor attacks may experience loud wheezes, whereas others with severe
attacks may not wheeze. The client with severe asthma attacks may have no audible wheezing because
of the decrease of airflow. For wheezing to occur, the client must be able to move sufficient air to
produce breath sounds. Wheezing usually occurs first on expiration. As the asthma attack progresses,
the client may wheeze during both inspiration and expiration. Priority Nursing Tip: During an acute
asthma attack, position the client in a high-Fowler’s or sitting position to aid in breathing. Test-Taking
Strategy: Use the ABCs—airway, breathing, and circulation. Note the strategic words “client’s respiratory
status is worsening.” Remember that diminished breath sounds indicate obstruction and impending
respiratory failure; this will direct you to select option 3. Also note that options 1, 2, and 4 are
comparable or alike and address wheezing. Review care of the client experiencing an asthma attack if
you had difficulty with this question. Reference Black, J., & Hawks, J. (2009). Medical-surgical nursing:
Clinical management for positive outcomes (8th ed., pp. 1571, 1573). St. Louis: Saunder

4. A nurse is performing an otoscopic examination

on a client with a suspected diagnosis of mastoiditis. The nurse would expect to note which of the

following if this disorder was present?

1 A mobile tympanic membrane

2 A transparent tympanic membrane

3 A pearly colored tympanic membrane

4 A thick and immobile tympanic membrane

Answer: 4 Rationale: Otoscopic examination in a client with mastoiditis reveals a red, dull, thick, and
immobile tympanic membrane with or without perforation. Options 1, 2, and 3 indicate normal findings
in an otoscopic examination. Priority Nursing Tip: Mastoiditis may be acute or chronic and results from
untreated or inadequately treated chronic or acute otitis media. Interventions focus on stopping the
infection before it spreads to other structures. Test-Taking Strategy: Use the process of elimination and
knowledge of normal assessment findings on an ear examination to direct you to option 4, the only
abnormal finding. Review the assessment findings associated with mastoiditis if you had difficulty with
this question. Reference Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: Patient-
centered collaborative care (6th ed., p. 1125). St. Louis: Saunders.

An adult client seeks treatment in an ambulatory care clinic for complaints of a left earache,

nausea, and a full feeling in the left ear. The

client has an elevated temperature. The nurse

first questions the client about:

1 A history of a recent brain abscess

2 Magnification of hearing in that ear

3 Relief of pain with acetaminophen (Tylenol)

4 A history of a recent upper respiratory infection (URI)

Answer: 4 Rationale: Otitis media in the adult is typically one-sided and presents as an acute process
with earache, nausea, and possible vomiting, fever, and fullness in the ear. The client may complain of
diminished hearing in that ear. The nurse takes a client history first, assessing whether the client has had
a recent URI. It is unnecessary to question the client about a brain abscess. The nurse may ask the client
if anything relieves the pain, but ear infection pain is usually not relieved until antibiotic therapy is
initiated. Priority Nursing Tip: Infants and children have eustachian tubes that are shorter, wider, and
straighter, which makes them more prone to otitis media. Test-Taking Strategy: Use the process of
elimination. Recalling the relationship between an upper respiratory infection and otitis media will
direct you to option 4. Review the causes of otitis media if you had difficulty with this question.
References Black, J., & Hawks, J. (2009). Medical-surgical nursing: Clinical management for positive
outcomes (8th ed., p. 1732). St. Louis: Saunders. Ignatavicius, D., & Workman, M. (2010). Medical-
surgical nursing: Patient-centered collaborative care (6th ed., p. 1123). St. Louis: Saunders.

A preschooler with a history of cleft palate repair

comes to the clinic for a routine well-child

checkup. To determine whether this child is

experiencing a long-term effect of cleft palate,

the nurse asks the parent which question?

1 “Does the child play with an imaginary

friend?”

2 “Was the child recently treated for

pneumonia?”

3 “Is the child unresponsive when given

directions?”

4 “Has the child had any difficulty swallowing

food?”