A client with rheumatoid arthritis is about to begin aspirin therapy to reduce inflammation. When teaching the client about aspirin, the nurse discusses adverse reactions to prolonged aspirin therapy. These include:
- A. Weight gain
- B. Respiratory acidosis
- C. Fine motor tremors
- D. Bilateral hearing loss
Correct Answer: D
Rationale: Prolonged aspirin therapy can lead to a rare side effect known as aspirin-induced hearing loss, which manifests as bilateral hearing loss. This adverse reaction is typically associated with higher doses of aspirin and longer durations of use. It is important for healthcare providers to monitor for signs of hearing loss in patients receiving long-term aspirin therapy, especially those with rheumatoid arthritis or other inflammatory conditions, to prevent irreversible damage to the hearing. Weight gain, respiratory acidosis, and fine motor tremors are not commonly associated with prolonged aspirin therapy.
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A 14-year-old boy is being admitted to the hospital for an appendectomy. Which roommate should the nurse assign with this patient?
- A. A 4-year-old boy post-appendectomy surgery
- B. A 6-year-old boy with pneumonia
- C. A 15-year-old boy admitted with a vasoocclusive sickle cell crisis
- D. A 12-year-old boy with cellulitis
Correct Answer: C
Rationale: The nurse should assign the 14-year-old boy recovering from an appendectomy to Roommate C, the 15-year-old boy admitted with a vasoocclusive sickle cell crisis. This decision is based on providing similar age groups and conditions for mutual support and understanding. Both patients are teenagers and are experiencing health challenges that involve pain management and supportive care. This pairing can offer emotional and social benefits as they navigate their hospital stay together. It is important to consider factors like age, condition, and potential social interactions when assigning roommates in a healthcare setting to promote a positive environment for healing and recovery.
During a breast examination, which finding most strongly suggests that the client has breast cancer?
- A. Slight asymmetry of the breasts
- B. A fixed nodular mass with dimpling of the overlying skin
- C. Bloody discharge from the nipple
- D. Multiple firm, round, freely movable masses that change with the menstrual cycle
Correct Answer: B
Rationale: A fixed nodular mass with dimpling of the overlying skin is the finding that most strongly suggests breast cancer. This presentation is concerning for an invasive carcinoma that has invaded into the surrounding tissues, leading to the dimpling of the skin. Breast cancer typically presents as a painless, hard, irregularly shaped, non-mobile mass. Dimpling of the skin overlying the mass is a sign of advanced disease and is often associated with a poor prognosis. Therefore, this finding should raise suspicion for breast cancer and prompt further evaluation and workup.
Use of condoms of those found to be infected with HIV
- A. 1 & 3
- B. 3 & 4
- C. 2 & 3 SITUATION; Mr. Baldo , 36 years old patient complaints of fatigue, weight loss, and low-grade fever. He also has pa in his fingers, elbows, and ankles.
Correct Answer: B
Rationale: In the given scenario involving Mr. Baldo presenting with symptoms of fatigue, weight loss, low-grade fever, and joint pain in fingers, elbows, and ankles, it is suggested that he may potentially have rheumatoid arthritis. Therefore, options 3 and 4 are the correct choices. Option 3 mentions the administration of NSAIDs (Nonsteroidal Anti-Inflammatory Drugs) for pain management, which is a common treatment approach for rheumatoid arthritis to help reduce inflammation and manage pain. Option 4 suggests consulting a rheumatologist for further evaluation and management, which is crucial in determining the appropriate diagnosis and treatment plan for Mr. Baldo's condition.
Why place an undershirt between the skin and the Pavlik harness?
- A. To keep the skin moist
- B. To prevent infection caused by pins of the Pavlik harness
- C. To prevent skin abrasions and irritation by the harness
- D. To keep the skin clean
Correct Answer: C
Rationale: Placing an undershirt between the skin and the Pavlik harness is done to prevent skin abrasions and irritation caused by the harness rubbing directly against the skin. The undershirt acts as a protective layer, reducing the likelihood of skin sensitivity or damage due to the continuous contact with the harness. This is particularly important for infants or young children who may have delicate skin that is more prone to irritation. By using an undershirt, caregivers can help ensure greater comfort for the child while wearing the Pavlik harness and reduce the risk of any skin-related complications.
The nurse is caring for a newborn receiving an exchange transfusion for hemolytic disease. Assessment of the newborn reveals slight respiratory distress and tachycardia. Which should the nurse's first action be?
- A. Notify practitioner.
- B. Stop the transfusion.
- C. Administer calcium gluconate.
- D. Monitor vital signs electronically.
Correct Answer: B
Rationale: Slight respiratory distress and tachycardia in a newborn during an exchange transfusion may indicate a possible transfusion reaction or overload. The first action the nurse should take is to stop the transfusion to prevent any further complications and assess the newborn's condition. After stopping the transfusion, the nurse can then take appropriate steps such as notifying the practitioner, administering medications, or providing supportive care as needed.
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