Nokea
A 21-year-old woman at 16 -weeks gestation undergoes an amniocentesis. The client asks the nurse what the physician will learn from this procedure. The nurse's response should be based on an understanding that which of the following conditions can be detected by this Test ?
- A. Tetralogy of Fallot.
- B. Talipes equinovarus.
- C. Hemolytic disease of the newborn.
- D. Cleft lip and palate.
Correct Answer: C
Rationale: maternal antibodies destroy fetal RBCs; bilirubin secreted because of hemolysis
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A client asks the home care nurse to look at the bruises on her arms and legs. The woman also tells the nurse that her gums bleed when she uses dental floss or brushes her teeth. The client is taking all of the following medications. Which is most likely related to the client's symptoms?
- A. Metformin (Glucophage)
- B. Estrogen (Premarin)
- C. Atenolol (Tenormin)
- D. Ibuprofen (Motrin)
Correct Answer: D
Rationale: Ibuprofen, an NSAID, can inhibit platelet function, causing bruising and bleeding gums. Other medications are less likely to cause these symptoms.
What are two major side effects of haloperidol (Haldol) the nurse should anticipate?
- A. Blood dyscrasia and extrapyramidal symptoms.
- B. Hearing loss and unsteady gait.
- C. Nystagmus and vertical gaze palsy.
- D. Alteration in level of consciousness and increased confusion.
Correct Answer: A
Rationale: major side effects of haloperidol (Haldol) include hematologic problems, primarily blood dyscrasia and extrapyramidal symptoms (EPS)
A client is being discharged following insertion of a permanent set pacemaker. A client with a permanent set pacemaker should be taught:
- A. To keep a loose dressing over the insertion site at all times
- B. That the pacemaker will function continuously at a set rate
- C. That increases in activity will require adjustments in the pacemaker setting
- D. That he will have to modify his lifestyle to allow for afternoon rest periods
Correct Answer: C
Rationale: Modern pacemakers adjust their rate based on activity (rate-responsive pacing), so the client should understand that increased activity may require pacemaker adjustments.
The nurse is preparing to change the dressing of a client with a venous access device. Because it is the first time the nurse has performed the skill, he reads the unit policy manual and asks another nurse how to best perform the dressing change. The skill level of the nurse at this time is best described as:
- A. Novice
- B. Proficient
- C. Competent
- D. Expert
Correct Answer: A
Rationale: A nurse performing a skill for the first time, relying on guidelines and assistance, is a novice. Higher levels require experience and independence.
A client is admitted with a diagnosis of myxedema. An initial assessment of the client would reveal the symptoms of:
- A. Slow pulse, weight loss, diarrhea, and cardiac failure
- B. Weight gain, lethargy, slowed speech, and decreased respiratory rate
- C. Rapid pulse, constipation, and bulging eyes
- D. Decreased body temperature, weight loss, and increased respiratory rate
Correct Answer: B
Rationale: Myxedema (severe hypothyroidism) causes weight gain, lethargy, slowed speech, and decreased respiratory rate due to slowed metabolism. Other options describe hyperthyroidism or mixed symptoms.