A client who had a biliopancreatic diversion procedure (BDP) 3 months ago is admitted with severe dehydration. Which assessment finding warrants immediate intervention by the nurse?
- A. Strong foul-smelling flatus
- B. Gastroccult positive emesis
- C. Complaint of poor night vision
- D. Loose bowel movements
Correct Answer: B
Rationale: Gastroccult positive emesis indicates gastrointestinal bleeding, which requires immediate intervention to prevent further complications.
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A 6-month-old infant is receiving digoxin (Lanoxin). The nurse should notify the practitioner and withhold the medication if the apical pulse is less than _______ beats/min.
- A. 60
- B. 70
- C. 90 to 110
- D. 110 to 120
Correct Answer: C
Rationale: If the 1-minute apical pulse is below 90 to 110 beats/min, the digoxin should not be given to a 6-month-old. Sixty beats/min is the cut-off for holding the digoxin dose in an adult; 70 beats/min is the determining heart rate to hold a dose of digoxin for an older child; 110 to 120 beats/min is an acceptable heart rate to administer digoxin to a 6-month-old.
The nurse reviews the laboratory results of a client during an annual physical examination and identifies a positive guaiac test of stool. Which additional serum laboratory test result should the nurse review?
- A. Glucose
- B. Platelet count
- C. White blood cell count
- D. Amylase
Correct Answer: B
Rationale: A positive guaiac test indicates gastrointestinal bleeding. A platelet count is essential to assess for thrombocytopenia, which could contribute to bleeding.
Manifestations of endocarditis include all of the following EXCEPT
- A. Gottron nodules
- B. hematuria
- C. petechiae
- D. splenomegaly
Correct Answer: A
Rationale: Gottron nodules are associated with dermatomyositis, not endocarditis.
In Asia, the following hepatitis virus appears to be a significant cause of viral myocarditis
- A. hepatitis E virus
- B. hepatitis B virus
- C. hepatitis C virus
- D. hepatitis D virus
Correct Answer: A
Rationale: Hepatitis E virus has been identified as a significant cause of viral myocarditis in Asia.
Hypothalamic nuclei are responsible for:
- A. Control of hunger
- B. Temperature control
- C. Maintaining osmolarity of extracellular fluid
- D. Secretion of thyrotrophin
Correct Answer: A
Rationale: The hypothalamus plays a key role in regulating hunger through various nuclei and hormonal signals.