Nokea
A client has a positive reaction to the Mantoux test. The nurse correctly interprets this reaction to mean that the client has:
- A. Active tuberculosis.
- B. Had contact with Mycobacterium tuberculosis.
- C. Developed a resistance to tubercle bacilli.
- D. Developed passive immunity to tuberculosis.
Correct Answer: B
Rationale: A positive Mantoux test indicates exposure to Mycobacterium tuberculosis, not necessarily active disease. It does not imply resistance or passive immunity.
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A client has had a nasogastric tube connected to low intermittent suction. The client is at risk for which of the following complications?
- A. Confusion.
- B. Muscle cramping.
- C. Edema.
- D. Tremors.
Correct Answer: B
Rationale: Nasogastric suction can cause electrolyte imbalances, such as hypokalemia, leading to muscle cramping due to loss of potassium-rich gastric fluid.
The nurse is caring for a client with suspected retinal detachment. Which of the following manifestations would not be consistent with a diagnosis of retinal detachment?
- A. Seeing 'floaters' in the field of vision
- B. A sense of having a curtain drawn over the eyes
- C. Flashes of light
- D. Intense pain in the affected eye
Correct Answer: D
Rationale: Retinal detachment typically presents with floaters, a curtain-like shadow, and flashes of light due to the retina pulling away from the underlying tissue. Intense pain is not a common symptom, as retinal detachment is usually painless.
The nurse explains to the client that a biopsy of the enlarged lymph node is important because, if Hodgkin's disease is present, the histologic examination will reveal which of the following?
- A. Tay-Sachs cells.
- B. Reed-Sternberg cells.
- C. Duchenne's cells.
- D. None of the above
Correct Answer: B
Rationale: Hodgkin's disease is diagnosed by the presence of Reed-Sternberg cells, large multinucleated cells, in the lymph node biopsy. Tay-Sachs and Duchenne's cells are unrelated to Hodgkin's.
Which stone type is associated with acidic urine?
- A. Calcium oxalate.
- B. Uric acid.
- C. Struvite.
- D. Cystine.
Correct Answer: B
Rationale: Uric acid stones form in acidic urine, requiring alkalinization.
The nurse is assessing a client with a casted arm for signs of infection. Which finding is most concerning?
- A. Mild itching under the cast.
- B. Foul odor from the cast.
- C. Warmth at the cast edges.
- D. Slight swelling of fingers.
Correct Answer: B
Rationale: A foul odor from the cast suggests infection, requiring immediate evaluation.