Nokea
A client whose father died from Huntington's chorea asks what the chances are that he will develop the disease. The nurse knows that the chances of the client developing the disease are:
- A. 25%
- B. 50%
- C. 100%
- D. 0%
Correct Answer: B
Rationale: Huntington's disease is autosomal dominant; with one affected parent, the client has a 50% chance of inheriting the gene and developing the disease.
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A patient has a Levin tube connected to intermittent low suction. At 7 AM, the nurse charts that there is 235 cc of greenish drainage in the suction container. At 3 PM, the nurse notes that there is 445 cc of greenish drainage in the suction container. Twice during the shift, the nurse irrigates the Levin tube with 30 cc of normal saline, as ordered by the physician. What is the actual amount of drainage from the nasogastric tube for the 7 to 3 shift?
- A. 150 cc.
- B. 210 cc.
- C. 295 cc.
- D. 385 cc.
Correct Answer: A
Rationale: 445-235=210-60=150
A client is going to have an endoscopy performed. Which of the following is not a probable reason for an endoscopy procedure?
- A. Aspiration noted on honey thick diet.
- B. Pain with a bowel movement
- C. Pain felt in the left upper quadrant
- D. Right shoulder pain
Correct Answer: B
Rationale: Bowel movement pain should be examined with a colonoscopy not an endoscopy.
A client with stage-four Parkinson's disease.
In developing discharge plans with the family of the client with stage-four Parkinson's disease, it is MOST important for the nurse to include which of the following activities?
- A. Ambulate twice daily.
- B. ROM exercise to all extremities four times a day.
- C. Include activities such as knitting and putting puzzles together.
- D. Encourage and provide writing materials.
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) client would be unable to ambulate (2) correct-in stage four Parkinson's disease, client is immobile (3) client cannot perform activities that require small-muscle dexterity (4) client cannot perform activities that require small-muscle dexterity
A 15-month old is admitted in sickle crisis. The parents ask why the child did not have any symptoms until now. What should be included in the nurse's response?
- A. The child was probably not exposed to it until recently.
- B. Antibodies from the mother are present for the first year of life.
- C. The symptoms do not manifest until the child is no longer breastfeeding.
- D. High fetal hemoglobin levels prevent symptoms for the first year of life.
Correct Answer: D
Rationale: High fetal hemoglobin (HbF) in infants inhibits sickling, delaying sickle cell anemia symptoms until HbF decreases around 6-12 months, replaced by adult hemoglobin.
The client is discharged from the unit with a prescription for Evista (raloxifene HCl). Which of the following is a side effect of this medication?
- A. Leg cramps
- B. Hot flashes
- C. Urinary frequency
- D. Cold extremities
Correct Answer: B
Rationale: Evista, used for osteoporosis, has an estrogen agonist effect, commonly causing hot flashes. It does not cause leg cramps , urinary frequency , or cold extremities .