Nokea
A client with a history of tuberculosis is admitted with complaints of hemoptysis. The nurse should give priority to:"
- A. Administering antibiotics
- B. Monitoring respiratory status
- C. Administering pain medication
- D. Monitoring blood pressure
Correct Answer: B
Rationale: Hemoptysis in tuberculosis indicates potential lung tissue damage, so monitoring respiratory status is critical to assess for airway compromise or worsening infection.
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When assessing a child with diabetes insipidus, the nurse should be aware of the cardinal signs of:
- A. Anemia and vomiting
- B. Polyuria and polydipsia
- C. Irritability relieved by feeding formula
- D. Hypothermia and azotemia
Correct Answer: B
Rationale: Anemia and vomiting are not cardinal signs of diabetes insipidus. Polyuria and polydipsia are the cardinal signs of diabetes insipidus. Irritability relieved by feeding water, not formula, is a common sign, but not the cardinal sign, of diabetes insipidus. Hypothermia and azotemia are signs, but not cardinal signs, of diabetes insipidus.
A 4-year-old child has Down syndrome. The community health nurse has coordinated a special preschool program. The nurse's primary goal is to:
- A. Provide respite care for the mother
- B. Facilitate optimal development
- C. Provide a demanding and challenging educational program
- D. Prepare child to enter mainstream education
Correct Answer: B
Rationale: The primary goal for a child with Down syndrome is to facilitate optimal growth and development through tailored interventions.
A 2-year-old boy is in the hospital outpatient department for observation after falling out of his crib and hitting his head. The nurse calls the physician to report:
- A. Evidence of perineal irritation
- B. Pulse fell from 102 to 96
- C. Pulse increased from 96 to 102
- D. Temperature rose to 102_F rectally
Correct Answer: D
Rationale: Perineal irritation needs to be addressed, but it is probably not necessary to call the physician. This fall in pulse rate remains within normal limits and is probably insignificant. It is important to monitor for continued change. This rise in pulse rate is probably not significant, but it is important to monitor for continued change. This temperature is above normal limits and needs medical investigation. It may or may not be related to the head injury.
A first-trimester primigravida is diagnosed with anemia. The nurse should suspect that this anemia is a result of:
- A. Mother's increased blood volume
- B. Mother's decreased blood volume
- C. Fetal blood volume increase
- D. Increase in iron absorption
Correct Answer: A
Rationale: Increased maternal blood volume in the first trimester causes dilutional anemia due to a relative decrease in red blood cell concentration.
The client is admitted with a diagnosis of abruptio placenta. Which complication is most likely to occur?
- A. Fetal distress
- B. Maternal hemorrhage
- C. Both A and B
- D. Neither A nor B
Correct Answer: C
Rationale: Abruptio placenta causes placental separation leading to fetal distress (from hypoxia) and maternal hemorrhage (from bleeding). Both are common and serious complications.