Nokea
A 2-year-old is hospitalized with suspected intussusception. Which finding is associated with intussusception?
- A. Currant jelly stools
- B. Projectile vomiting
- C. Ribbonlike stools
- D. Palpable mass over the flank
Correct Answer: A
Rationale: Currant jelly stools, caused by blood and mucus, are a hallmark of intussusception due to intestinal obstruction.
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The client is having fetal heart rates of 100-110 beats per minute during the contractions. The first action the nurse should take is to:
- A. Apply an internal monitor
- B. Turn the client to her side
- C. Get the client up and walk her in the hall
- D. Move the client to the delivery room
Correct Answer: B
Rationale: Turning the client to her side improves uteroplacental perfusion, addressing fetal bradycardia during contractions.
Which instruction would not be included in the discharge teaching of the client receiving chlorpromazine (Thorazine)?
- A. You will need to wear protective clothing or a sunscreen when you are outside.'
- B. You will need to avoid eating aged cheese.'
- C. You should carry hard candy with you to decrease dryness of the mouth.'
- D. You should report a sore throat immediately.'
Correct Answer: B
Rationale: Avoiding aged cheese is relevant for MAO inhibitors, not chlorpromazine, which does not interact with tyramine-containing foods.
The client with a cervical fracture is placed in traction. Which type of traction will be utilized at the time of discharge?
- A. Russell's traction
- B. Buck's traction
- C. Halo traction
- D. Crutchfield tong traction
Correct Answer: C
Rationale: Halo traction is used for cervical fractures and can be maintained post-discharge for stabilization.
A client is admitted to the unit 2 hours after an injury with second-degree burns to the face, trunk, and head. The nurse would be most concerned with the client developing what?
- A. Hypovolemia
- B. Laryngeal edema
- C. Hypernatremia
- D. Hyperkalemia
Correct Answer: B
Rationale: Laryngeal edema is a critical concern with facial and head burns due to the risk of airway obstruction.
The nurse is caring for a client with a diagnosis of major depressive disorder. Which of the following client statements would indicate that the client is responding positively to the prescribed antidepressant therapy?
- A. I feel like my energy level is starting to improve.
- B. I still don’t enjoy doing things I used to love.
- C. I have trouble sleeping through the night.
- D. I feel worthless and don’t want to see anyone.
Correct Answer: A
Rationale: improved energy level is a positive sign of response to antidepressant therapy