Nokea
A client comes to the clinic complaining of weight loss, fatigue, and a low-grade fever. Physical examination reveals a slight enlargement of the cervical lymph nodes. To assess possible causes for the fever, it would be most appropriate for the nurse to initially ask: a."Have you bee sexually active lately?" b, "Do you have a sore throat at the present time?"
- A. "Have you been exposed recently to anyone with an infection?"
- B. "When did you first notice that your temperature had gone up?"
Correct Answer: A
Rationale: Rationale:
- The correct answer is A, "Have you been exposed recently to anyone with an infection?" because it helps assess potential sources of infection causing the low-grade fever and other symptoms.
- Choice B is irrelevant as the client's current sore throat is not the main concern.
- Choice C and D do not address the potential infectious etiology of the symptoms.
- Overall, assessing recent exposure to infections is crucial in identifying possible sources of the client's symptoms.
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A client agreed to become an organ donor is pronounced dead. What is the most important factor in selecting a transplant recipient?
- A. Blood relationship
- B. Compatible blood and tissue types
- C. Sex and size
- D. Need
Correct Answer: B
Rationale: The correct answer is B: Compatible blood and tissue types. This is crucial to minimize the risk of rejection and ensure a successful transplant. Matching blood and tissue types help prevent the recipient's immune system from attacking the new organ. Blood relationship (A) is not as important as compatibility. Sex and size (C) are important considerations for certain transplants but not the most crucial factor. Need (D) is relevant but does not outweigh the importance of compatibility to ensure a successful transplant.
A client, age 42, visits the gynecologist. After examining her, the physician suspects cervical cancer. The nurse reviews the client’s history for risk factors for this disease. Which history finding is a risk factor for cervical cancer?
- A. Onset of sporadic sexual activity at age 17
- B. Spontaneous abortion at age 19
- C. Pregnancy complicated with eclampsia at age 27
- D. Human papilloma virus infection at age 32
Correct Answer: D
Rationale: The correct answer is D: Human papilloma virus (HPV) infection at age 32. HPV infection is a well-known risk factor for cervical cancer as certain strains of HPV can lead to cellular changes in the cervix that may progress to cancer. Here's the rationale:
1. HPV is a known risk factor: HPV is a sexually transmitted infection that is strongly linked to the development of cervical cancer.
2. Age of infection: The client's history of acquiring HPV at age 32 is significant as long-standing HPV infection increases the risk of cervical cancer.
3. Other choices are not directly linked: Choices A, B, and C are not directly associated with an increased risk of cervical cancer. Age of sexual activity onset, spontaneous abortion, and eclampsia are not established risk factors for cervical cancer.
The nurse is aware that the shift of body fluids associated with the intravenous administration of albumin occurs by the process of:
- A. Filtration
- B. Osmosis
- C. Diffusion
- D. Active Transport
Correct Answer: A
Rationale: The correct answer is A: Filtration. Albumin is a large protein molecule that cannot pass through the semipermeable membrane of blood vessels. Therefore, the shift of body fluids associated with intravenous albumin administration occurs through the process of filtration, where fluid moves across the membrane due to a pressure difference. Osmosis (B) involves the movement of water across a semipermeable membrane, which is not the case for albumin. Diffusion (C) is the movement of molecules from an area of high concentration to low concentration, which is not how albumin moves. Active transport (D) requires energy to move substances against a concentration gradient, which is not the mechanism for albumin movement in the body.
What deficits would the nurse expect in a right-handed person experiencing a stroke affecting the left side of the cortex?
- A. Expressive aphasia and paralysis on the right side of the body.
- B. Expressive aphasia and paralysis on the left side of the body. .
- C. Dysarthria and paralysis on the right side of the body.
- D. Mixed aphasia and paralysis on the right side of the body.
Correct Answer: A
Rationale: The correct answer is A: Expressive aphasia and paralysis on the right side of the body. In a right-handed person, the left side of the brain controls language and right-sided motor function. A stroke affecting the left side of the cortex would lead to expressive aphasia due to damage to Broca's area, causing difficulty in speaking and forming words. Paralysis on the right side of the body would result from damage to the motor cortex in the left hemisphere. Choices B, C, and D are incorrect because they do not align with the typical deficits seen in a person with a stroke affecting the left side of the cortex in a right-handed individual.
Which of the following is one of the discharge criteria from ambulatory surgery for patients following surgery?
- A. Able to drive self home
- B. IV narcotics given less than 30 minutes
- C. Has home telephone before discharge
- D. Understands discharge instructions
Correct Answer: D
Rationale: The correct answer is D: Understands discharge instructions. This is crucial for patient safety and recovery post-surgery. Understanding discharge instructions ensures patients know how to care for themselves at home, manage medications, recognize warning signs, and follow-up instructions. Choice A is incorrect as patients should not drive after surgery due to potential impairment. Choice B is incorrect as IV narcotics administration timing is not a discharge criterion. Choice C is irrelevant to the patient's readiness for discharge. Understanding discharge instructions is the key factor in ensuring the patient's well-being and recovery after ambulatory surgery.