Nokea
A 6-month-old infant is admitted with a diagnosis of bacterial meningitis. The nurse should expect to observe which of the following symptoms?
- A. Positive Babinski reflex.
- B. High-pitched cry.
- C. Hypothermia.
- D. Kernig's sign.
Correct Answer: B
Rationale: A high-pitched cry is a common symptom of bacterial meningitis in infants, indicating neurological irritation.
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A client with a history of liver failure is admitted with hepatic encephalopathy. The nurse should monitor the client for which of the following?
- A. Asterixis.
- B. Hypotension.
- C. Polyuria.
- D. Bradycardia.
Correct Answer: A
Rationale: Asterixis (flapping tremor) is a hallmark sign of hepatic encephalopathy due to ammonia buildup.
A nurse is about to conduct a sexual history for a 16-year-old female who is accompanied by her mother. What is an appropriate question for the nurse to ask this client or her mother?
- A. What do you think about having your mother leave the room?'
- B. Mother, do you think your daughter is sexually active?'
- C. Mother, I am going to ask you to wait a few minutes in the waiting room now so I can complete the health history with your daughter.'
- D. The two of you seem like you share everything. I am going to ask questions about sexual history now.'
Correct Answer: C
Rationale: Requesting the mother to leave ensures privacy for the teen, promoting honest responses during the sexual history.
A newborn infant is diagnosed with imperforate anus. Which description of this disorder should the nurse provide to the parents?
- A. The presence of fecal incontinence
- B. Incomplete development of the anus
- C. The infrequent and difficult passage of dry stools
- D. Invagination of a section of the intestine into the distal bowel
Correct Answer: B
Rationale: Imperforate anus (anal atresia, anal agenesis) is the incomplete development or absence of the anus in its normal position in the perineum. Option 1 describes encopresis. Encopresis generally affects preschool and school-age children. Option 3 describes constipation. Constipation can affect any child at any time, although it peaks at age 2 to 3 years. Option 4 describes intussusception.
The nurse should tell a client who is scheduled for a bone marrow biopsy that the specimen can be withdrawn from which site?
- A. Ribs
- B. Femur
- C. Scapula
- D. Sternum
Correct Answer: D
Rationale: The most common sites for bone marrow biopsy in the adult are the iliac crest and the sternum. These areas are rich in bone marrow and are easily accessible for testing. The femur, scapula, and ribs are not sites for bone marrow biopsy.
A client with a diagnosis of gout is prescribed allopurinol (Zyloprim). The nurse should instruct the client to:
- A. Take the medication with food to reduce stomach upset.
- B. Avoid drinking alcohol.
- C. Limit fluid intake.
- D. Take the medication at bedtime only.
Correct Answer: A,B
Rationale: Taking allopurinol with food reduces gastrointestinal upset, and avoiding alcohol prevents uric acid buildup.