Nokea
The nurse is collecting data from a client with primary adrenal insufficiency (Addison disease). Which of the following findings is consistent with the condition?
- A. Bronze pigmentation of the skin
- B. Increased body and facial hair
- C. Purple or red striae on the abdomen
- D. Supraclavicular fat pad
Correct Answer: A
Rationale: Bronze skin pigmentation (A) is a hallmark of Addison disease due to increased ACTH stimulating melanocytes. Increased hair (B) and supraclavicular fat pad (D) are associated with Cushing syndrome, while striae (C) are nonspecific but not typical of Addison disease.
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A woman who had a tuberculosis test three days ago reports to the nurse to have the test read. Which finding, if present, indicates a positive result and a need for referral and follow-up?
- A. A red area 12 mm in diameter
- B. A raised area 10 mm in diameter
- C. Itching at the injection site
- D. A rash on the arm near the test site
Correct Answer: B
Rationale: A raised (indurated) area >10 mm indicates a positive TB skin test, requiring follow-up for potential latent or active TB.
The family of a 90-year-old resident in a long-term care facility asks the nurse why the client only gets a shower three times a week. What information is most important for the nurse to include when answering the question?
- A. The staff members have limited time and must schedule all the residents.
- B. The client's skin is dry; too many showers will dry the skin further.
- C. The client has limited energy and must conserve it.
- D. The client is not very active and doesn't get very dirty.
Correct Answer: B
Rationale: Frequent showers can exacerbate dry skin in elderly clients, increasing irritation or breakdown risk. Staffing, energy, or activity levels are less relevant to skin health.
The nurse is assessing a client in the emergency room. Which statement suggests that the problem is acute angina?
- A. My pain is deep in my chest behind my breast bone.
- B. When I sit up the pain gets worse.
- C. As I take a deep breath the pain gets worse.
- D. The pain is right here in my stomach area.
Correct Answer: A
Rationale: My pain is deep in my chest behind my breast bone. This describes the typical substernal pain of acute angina.
The nurse is planning care for an 11-year-old child with attention deficit hyperactivity disorder who is hospitalized for surgical treatment of a fractured femur. What is the priority nursing action?
- A. Create a structured and consistent environment with a daily schedule
- B. Give the child a written schedule of activities
- C. Provide a verbal explanation of what to expect during hospitalization
- D. Restrict visitors while the child is hospitalized
Correct Answer: A
Rationale: A structured environment (A) supports ADHD management by reducing overstimulation and providing predictability, critical for a hospitalized child. Written schedules (B) and verbal explanations (C) are secondary, and restricting visitors (D) is unnecessary.
The nurse is caring for an infant who has a prescription for amoxicillin 25 mg/kg/day in 2 divided doses. The client weighs 16.5 lb (7.5 kg). The nurse has amoxicillin oral suspension 125 mg/5 mL available. How many mL should the nurse administer to the client with each dose? Record your answer using 2 decimal places.
Correct Answer: 3.75 mL/dose
Rationale: Calculation: 7.5 kg × 25 mg/kg/day = 187.5 mg/day. Divided into 2 doses = 93.75 mg/dose. 125 mg/5 mL = 25 mg/mL. 93.75 mg ÷ 25 mg/mL = 3.75 mL/dose (A).