Nokea
A client with Addison's disease will most likely exhibit which symptom?
- A. Hypertension
- B. Bronze pigmentation
- C. Hirsutism
- D. Purple striae
Correct Answer: B
Rationale: A bronze pigmentation is a sign of Addison's disease. Answers A, C, and D are symptoms of Cushing's syndrome, making them incorrect.
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The nurse assigns an unlicensed assistive personnel (UAP) to care for a client with a musculoskeletal disorder. The client ambulates with a leg splint. Which task requires supervision of the UAP?
- A. Report signs of redness overlying a joint
- B. Monitor the client's response to ambulatory activity
- C. Encouragement for the independence in self-care
- D. Assist the client to transfer from a bed to a chair
Correct Answer: B
Rationale: Monitor the client's response to interventions requires assessment, a task to be performed by an RN.
A diabetic multigravida is scheduled for an amniocentesis at 32 weeks gestation to determine the L/S ratio and phosphatidyl glycerol level. The L/S ratio is 1:1 and the presence of phosphatidyl glycerol is noted. The nurse's assessment of this data is:
- A. The infant is at low risk for congenital anomalies.
- B. The infant is at high risk for intrauterine growth retardation.
- C. The infant is at high risk for respiratory distress syndrome.
- D. The infant is at high risk for birth trauma.
Correct Answer: C
Rationale: An L/S ratio of 1:1 and presence of phosphatidyl glycerol suggest immature lungs, indicating a high risk for respiratory distress syndrome, so C is correct. Answers A, B, and D are not directly related to these findings.
The nurse reinforces education to the parent of a child who was diagnosed with attention-deficit hyperactivity disorder and received a prescription of methylphenidate. Which statement by the parent best demonstrates that teaching has been effective?
- A. An additive-free, low-sugar diet will reduce my child's symptoms.'
- B. I can now manage my child's condition on my own.'
- C. My child should take the last daily dose of methylphenidate before 6:00 PM.'
- D. Once the medication is started, I will not have to monitor my child anymore.'
Correct Answer: C
Rationale: Taking methylphenidate before 6:00 PM (C) prevents sleep disruption, indicating effective teaching. Diet changes (A), self-management (B), and no monitoring (D) are incorrect or incomplete.
The nurse is reviewing laboratory test results for an 80-year-old client who has a methicillin-resistant Staphylococcus aureus infection and is receiving vancomycin. Which of the following test results would require immediate follow-up?
- A. elevated BUN
- B. decreased serum iron level
- C. decreased serum triglyceride level
- D. elevated capillary blood glucose level
Correct Answer: A
Rationale: Elevated BUN (A) may indicate nephrotoxicity, a serious side effect of vancomycin requiring immediate follow-up. Decreased iron (B) or triglycerides (C) are not directly related to vancomycin toxicity. Elevated glucose (D) may need monitoring but is less urgent.
A nurse aide is taking care of a 2 year-old child with Wilm's tumor. The nurse aide asks the nurse why there is a sign above the bed that says DO NOT PALPATE THE ABDOMEN? The best response by the nurse would be which of these statements?
- A. Touching the abdomen could cause cancer cells to spread.'
- B. Examining the area would cause difficulty to the child.'
- C. Pushing on the stomach might lead to the spread of infection.'
- D. Placing any pressure on the abdomen may cause an abnormal experience.'
Correct Answer: A
Rationale: Manipulation of the abdomen can lead to dissemination of cancer cells to nearby and distant areas. Bathing and turning the child should be done carefully.