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A client who took a camping vacation two weeks ago in a county with a tropical climate comes to the clinic describing vague symptoms and diarrhea for the past week. Which finding is most important for the nurse report to the healthcare provider?
- A. Weakness and fatigue
- B. Intestinal cramping
- C. Weight loss
- D. Jaundiced sclera
Correct Answer: D
Rationale: Jaundiced sclera indicates possible liver involvement, which could be due to a tropical disease such as hepatitis or leptospirosis.
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Corneal opacities are seen in:
- A. Marfan's syndrome
- B. Herpes simplex infection
- C. Hurler syndrome
- D. Osteogenesis imperfecta
Correct Answer: C
Rationale: Corneal opacities are a characteristic feature of Hurler syndrome, a type of mucopolysaccharidosis.
Diamond Blackfan anemia is different from Transient Erythroblastopenia of Childhood as the former has
- A. Increased adenosine deaminase
- B. Mean corpuscular volume is decreased
- C. Female predominance
- D. Antecedent history of viral illness
Correct Answer: A
Rationale: Diamond Blackfan anemia is characterized by increased adenosine deaminase activity, unlike Transient Erythroblastopenia of Childhood.
A nurse assesses a client 2 hours after a cardiac angiography via the left femoral artery. The nurse notes that the left pedal pulse is weak. Which action should the nurse take?
- A. Elevate the leg and apply a sandbag to the entrance site.
- B. Increase the flow rate of intravenous fluids.
- C. Assess the color and temperature of the left leg.
- D. Document the finding as the left pedal pulse of +1/4.
Correct Answer: C
Rationale: A weak pedal pulse after cardiac angiography may indicate compromised blood flow. Assessing the color and temperature of the leg helps determine if there is ischemia or other complications.
An adult woman with primary Raynaud phenomenon develops pallor and then cyanosis of her fingers. After warming her hands, the fingers turn red and the client reports a burning sensation. What action should the nurse take?
- A. Apply a cool compress to the affected fingers for 20 minutes
- B. Secure a pulse oximeter to monitor the client's oxygen saturation
- C. Report the finding to the healthcare provider as soon as possible
- D. Continue to monitor the fingers until color returns to normal
Correct Answer: D
Rationale: Monitoring is appropriate as the symptoms are consistent with Raynaud's phenomenon and should resolve with warming.
A client with urolithiasis is preparing for discharge after lithotripsy. Which intervention should the nurse include in the client's postoperative discharge instructions?
- A. Prepare for transcutaneous pacing
- B. Deliver another defibrillator shock
- C. Administer IV Epinephrine per ACLS protocol
- D. Give IV dose of adenosine rapidly over 1-2 seconds
Correct Answer: D
Rationale: The client may experience arrhythmia, and the correct intervention is giving IV adenosine to slow the heart rate.