Nokea
A client is admitted with suspected Hodgkin's lymphoma. The diagnosis is confirmed by the:
- A. Overproliferation of immature white cells
- B. Presence of Reed-Sternberg cells
- C. Increased incidence of microcytosis
- D. Reduction in the number of platelets
Correct Answer: B
Rationale: Hodgkin's lymphoma is diagnosed by the presence of Reed-Sternberg cells in lymph node biopsy, a hallmark of the disease.
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The nurse is caring for a client with a history of Sjögren’s syndrome. The nurse should expect the client to have:
- A. Dry eyes and mouth
- B. Joint swelling
- C. Fever
- D. Chest pain
Correct Answer: A
Rationale: Sjögren’s syndrome is an autoimmune condition causing reduced salivary and lacrimal gland function, leading to dry eyes and mouth.
The nurse is caring for an adolescent with a five-year history of bulimia. A common clinical finding in the client with bulimia is:
- A. Extreme weight loss
- B. Dental caries
- C. Hair loss
- D. Decreased temperature
Correct Answer: B
Rationale: Frequent vomiting in bulimia exposes teeth to stomach acid, leading to dental caries (tooth decay), a common clinical finding.
The client is admitted with a diagnosis of gestational diabetes. Which fetal monitoring technique is most appropriate?
- A. Non-stress test
- B. Biophysical profile
- C. Both A and B
- D. Neither A nor B
Correct Answer: C
Rationale: Gestational diabetes increases fetal risks (e.g. macrosomia hypoglycemia) requiring close monitoring. Non-stress tests assess fetal heart rate and biophysical profiles evaluate fetal well-being comprehensively. Both are appropriate.
The nurse is assessing elderly clients at a community center.
- A. Dry mouth
- B. Loss of one inch of height in the last year
- C. Stiffened joints
- D. Rales bilaterally on chest auscultation
Correct Answer: D
Rationale: Rales bilaterally indicate possible pulmonary edema or infection, which are serious conditions requiring immediate attention. Dry mouth (A), height loss (B), and stiffened joints (C) are common in aging but less urgent.
A 5-year-old child is hospitalized for an acute illness. The nurse encourages the family to bring her favorite objects from home. What is the nurse's rationale?
- A. To reduce fear of the unknown
- B. To keep the child calm
- C. To establish a trusting relationship
- D. To prevent or minimize separation anxiety
Correct Answer: D
Rationale: Favorite objects from home assist in creating a familiar setting, preventing or minimizing separation anxiety.