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A client is being discharged from the hospital tomorrow following a colon resection with a left colostomy. The nurse knows that the client understands the discharge teaching about care of her colostomy when she says:
- A. I know that I am not supposed to irrigate my colostomy.'
- B. My stool will be soft like paste.'
- C. My stoma should be red and slightly raised.'
- D. The skin around my stoma may become irritated from the enzymes in my stool.'
Correct Answer: C
Rationale: The healthy stoma should be red and slightly raised. If it begins to turn dark or blue, the client should see the physician immediately.
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A newborn infant is exhibiting signs of respiratory distress. Which of the following would the nurse recognize as the earliest clinical sign of respiratory distress?
- A. Cyanosis
- B. Increased respirations
- C. Sternal and subcostal retractions
- D. Decreased respirations
Correct Answer: C
Rationale: Sternal and subcostal retractions are the earliest sign of respiratory distress in newborns, indicating increased ventilatory effort.
The nurse needs to be aware that the most common early complication of a myocardial infarction is:
- A. Diabetes mellitus
- B. Anaphylactic shock
- C. Cardiac hypertrophy
- D. Cardiac dysrhythmia
Correct Answer: D
Rationale: Myocardial infarction causes tissue damage, which may interrupt electrical impulses. Myocardial irritability results from lack of oxygenated tissue.
The nurse is caring for a client with leukemia who is receiving the drug doxorubicin (Adriamycin). Which toxic effects of this drug would be reported to the physician immediately?
- A. Rales and distended neck veins
- B. Red discoloration of the urine
- C. Nausea and vomiting
- D. Elevated BUN and dry, flaky skin
Correct Answer: A
Rationale: Rales and distended neck veins suggest cardiotoxicity (e.g., heart failure), a serious doxorubicin side effect requiring immediate reporting. Red urine (B) is expected, nausea/vomiting (C) are common, and BUN/skin changes (D) are less urgent.
A healthcare worker is referred to the nursing office with a suspected latex allergy. The first symptom of latex allergy is usually:
- A. Oral itching after eating bananas
- B. Swelling of the eyes and mouth
- C. Difficulty in breathing
- D. Swelling and itching of the hands
Correct Answer: D
Rationale: Latex allergy often first presents as localized skin reactions, such as swelling and itching of the hands, due to direct contact with latex products.
A client admitted to the psychiatric unit claims to be the Pope and insists that he will not be kept away from his followers. The most likely explanation for the client's delusion is:
- A. A reaction formation
- B. A stressful event
- C. Low self-esteem
- D. Overwhelming anxiety
Correct Answer: C
Rationale: Delusions of grandeur, like claiming to be the Pope, often stem from low self-esteem in psychiatric disorders like schizophrenia, compensating for feelings of inadequacy. The other factors are less specific.