Nokea
A client has immune thrombocytopenic purpura. The client's platelet count is 19,000. Which initial treatment does the nurse expect?
- A. Splenectomy
- B. Immunosuppressive therapy
- C. Observation only
- D. Platelet administration
Correct Answer: B
Rationale: For ITP with a platelet count of 19,000, immunosuppressive therapy (B), like corticosteroids, is typically initial to increase platelet production. Splenectomy (A) is later, observation (C) is risky, and platelets (D) are less effective.
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During the assessment of a laboring client, the nurse notes that the FHT are loudest in the upper-right quadrant. The infant is most likely in which position?
- A. Right breech presentation
- B. Right occipital anterior presentation
- C. Left sacral anterior presentation
- D. Left occipital transverse presentation
Correct Answer: A
Rationale: Fetal heart tones loudest in the upper-right quadrant suggest a breech presentation, with the fetus's heart higher in the uterus.
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.
A client suspected of having Alzheimer's disease is evaluated using the Mini-Mental State Examination. At the beginning of the evaluation, the examiner names three objects. Later in the evaluation, he asks the client to name the same three objects. The examiner is testing the client's:
- A. Attention
- B. Orientation
- C. Recall
- D. Registration
Correct Answer: C
Rationale: Recalling three objects tests short-term memory (recall), a key component assessed in the Mini-Mental State Examination for Alzheimer's.
The nurse is caring for a client post-myocardial infarction on the cardiac unit. The client is exhibiting symptoms of shock. Which clinical manifestation is the best indicator that the shock is cardiogenic rather than anaphylactic?
- A. BP 90/60
- B. Chest pain
- C. Anxiety
- D. Temp 98.6°F
Correct Answer: B
Rationale: Chest pain is a hallmark of cardiogenic shock due to myocardial infarction, reflecting cardiac ischemia. Anaphylactic shock typically involves allergic symptoms like urticaria or bronchospasm. Low BP, anxiety, and normal temperature are nonspecific.
The nurse is preparing to administer a unit of red blood cells (RBCs) to an anemic client. From starting the infusion (puncturing the blood pack) to completion, infusion of the pack should occur within which time period?
- A. 8 hours
- B. 6 hours
- C. 4 hours
- D. 2 hours
Correct Answer: C
Rationale: RBC transfusions must be completed within 4 hours to minimize bacterial growth and ensure safety.