A client with pheochromocytoma reports the onset of a severe headache. The nurse observes that the client is very diaphoretic. Which assessment data should the nurse obtain next?
- A. Blood pressure
- B. Blood glucose level
- C. Respiratory rate
- D. Oxygen saturation
Correct Answer: A
Rationale: Pheochromocytoma can lead to hypertension, which may be responsible for the client’s symptoms. Monitoring blood pressure is crucial to assess for potential hypertensive crisis.
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A VII nerve injury at the exit from the stylomastoid foramen would explain all except:
- A. Loss of sensation over the vallecula
- B. Loss of taste over the anterior third of the tongue
- C. Increased responsiveness to loud noises
- D. Inability to open the ipsilateral eye
Correct Answer: D
Rationale: The correct answer is D because the facial nerve (VII) does not control eye opening; this is controlled by the oculomotor nerve (III). The other options (a, b, c, e) are consistent with a VII nerve injury.
The following antibiotics interfere with bacterial translation:
- A. Penicillin
- B. Ceftriaxone
- C. Azithromycin
- D. Ciprofloxacin
Correct Answer: C
Rationale: Azithromycin, a macrolide antibiotic, inhibits bacterial protein synthesis by binding to the 50S ribosomal subunit, thereby interfering with translation.
Drug of choice for infective endocarditis due to HACEK organisms is
- A. Vancomycin
- B. Gentamicin
- C. Ampicillin
- D. Ceftriaxone
Correct Answer: D
Rationale: Ceftriaxone is the drug of choice for infective endocarditis due to HACEK organisms.
A client with hypothyroidism reports difficulty falling asleep because of feelings of depression. Which action should the nurse implement?
- A. Review most recent thyroid function test results
- B. Encourage the client to take an afternoon nap.
- C. Refer the client for a psychiatric evaluation.
- D. Suggest reducing fluid intake before bedtime.
Correct Answer: A
Rationale: Hypothyroidism can cause depression and sleep disturbances. Reviewing thyroid function tests helps determine if the symptoms are related to inadequate thyroid hormone levels.
Common presenting features of myotonic dystrophy are:
- A. Floppy infant
- B. Corneal opacities
- C. Frontal baldness
- D. Macro-orchidism
Correct Answer: D
Rationale: Macro-orchidism: Myotonic dystrophy is characterized by muscle weakness and myotonia. Macro-orchidism (enlarged testes) is a distinctive feature, especially in male patients.