A client is admitted to the hospital with a temperature of 99.8°F, complaints of blood-tinged hemoptysis, fatigue, and night sweats. The client's symptoms are consistent with a diagnosis of:
- A. Pneumonia
- B. Reaction to antiviral medication
- C. Tuberculosis
- D. Superinfection due to low CD4 count
Correct Answer: C
Rationale: The symptoms of low-grade fever, blood-tinged hemoptysis, fatigue, and night sweats are classic for tuberculosis.
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The nurse is assisting in the assessment of the patient admitted with 'extreme abdominal pain.' The nurse asks the client about the medication that he has been taking because:
- A. Interactions between medications will cause abdominal pain.
- B. Various medications taken by mouth can affect the alimentary tract.
- C. This will provide an opportunity to educate the patient regarding the medications used.
- D. The types of medications might be attributable to an abdominal pathology not already identified.
Correct Answer: D
Rationale: Medications can cause or exacerbate abdominal pathology, making it essential to assess their role in the patient's symptoms.
The mother of a male child with cystic fibrosis tells the nurse that she hopes her son's children won't have the disease. The nurse is aware that:
- A. There is a 25% chance that his children will have cystic fibrosis.
- B. Most of the males with cystic fibrosis are sterile.
- C. There is a 50% chance that his children will be carriers.
- D. Most males with cystic fibrosis are capable of having children, so genetic counseling is advised.
Correct Answer: B
Rationale: Most males with cystic fibrosis are sterile due to congenital absence of the vas deferens, significantly reducing the likelihood of having biological children.
The nurse must administer 120 mg of amoxicillin oral suspension to a child. However, the only dosage available in the pharmacy is 200 mg per 5 mL. How many milliliters of suspension should the nurse administer? Record your answer using a whole number only.
Correct Answer: 3
Rationale: Dose = 120 mg, concentration = 200 mg/5 mL = 40 mg/mL. Volume = 120 m/40 mg/mL = 3 mL.
Six hours after birth, the infant is found to have an area of swelling over the right parietal area that does not cross the suture line. The nurse should chart this finding as:
- A. A cephalhematoma
- B. Molding
- C. Subdural hematoma
- D. Caput succedaneum
Correct Answer: A
Rationale: A cephalhematoma is a subperiosteal hemorrhage that does not cross suture lines, commonly seen in newborns.
Which of the following nursing actions has the HIGHEST priority for a teenager admitted with burns to 50% of his body?
- A. Counseling regarding problems of body image.
- B. Maintain airborne precautions.
- C. Maintain aseptic technique during procedures.
- D. Encourage peers to visit on a regular basis.
Correct Answer: C
Rationale: safety is a priority for the client who is at high risk for infection
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