Nokea
A client telephones the clinic to ask about a home pregnancy test she used this morning. The nurse understands that the presence of which hormone strongly suggests a woman is pregnant?
- A. Estrogen
- B. HCG
- C. Alpha-fetoprotein
- D. Progesterone
Correct Answer: B
Rationale: Human chorionic gonadotropin (HCG) is the biologic marker on which pregnancy tests are based. Reliability is about 98%, but the test does not conclusively confirm pregnancy.
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A client with a C6 spinal injury begins to complain of a severe headache. When assessing the client, the nurse notes that her BP is $190 / 100$ and she is diaphoretic. Which of the following nursing actions is most appropriate at this time?
- A. Increase the rate of IV fluids.
- B. Make sure the Foley catheter is patent.
- C. Place the client flat in bed.
- D. Administer oxygen.
Correct Answer: B
Rationale: These symptoms indicate autonomic dysreflexia, often triggered by a blocked catheter; ensuring the Foley catheter is patent is the priority.
Of the following combination of symptoms the most indicative of increased intracranial pressure is:
- A. Weak rapid pulse, normal blood pressure, intermittent fever, lethargy.
- B. Rapid weak pulse, fall in blood pressure, low temperature, restlessness.
- C. Slow bounding pulse, rising blood pressure, elevated temperature, stupor.
- D. Slow bounding pulse, fall in blood pressure, temperature below 97°F, stupor.
Correct Answer: C
Rationale: Slow pulse, rising BP, and stupor indicate Cushing's triad, a sign of increased intracranial pressure.
The nurse is assessing a 2 year-old client with a possible diagnosis of congenital heart disease. Which of these is most likely to be seen with this diagnosis?
- A. Several otitis media episodes in the last year
- B. Weight and height in the 10th percentile since birth
- C. Takes frequent rest periods while playing
- D. Changing food preferences and dislikes
Correct Answer: C
Rationale: Takes frequent rest periods while playing. Children with heart disease self-limit activity due to exercise intolerance.
The nurse is assessing a client with a history of liver cirrhosis. Which of the following findings would the nurse expect?
- A. Jaundice and ascites.
- B. Chest pain and dyspnea.
- C. Frequent urinary tract infections.
- D. Bilateral leg edema.
Correct Answer: A
Rationale: Jaundice (from bilirubin buildup) and ascites (from portal hypertension) are classic signs of liver cirrhosis. Chest pain/dyspnea (B) suggest cardiac issues, UTIs (C) are unrelated, and leg edema (D) is more typical of heart failure.
Which normal findings complement the physical assessment?
- A. The boy is Asian
- B. The boy is from Europe.
- C. The boy is American.
- D. The boy is probably malnourished.
Correct Answer: D
Rationale: Malnutrition explains being underweight and small for age, complementing the assessment.