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A client's health history is suggestive of inflammatory bowel disease. Which of the following would suggest Crohn disease, rather than ulcerative colitis, as the cause of the client's signs and symptoms?
- A. A pattern of distinct exacerbations and remissions
- B. Severe diarrhea
- C. An absence of blood in stool
- D. Involvement of the rectal mucosa
Correct Answer: C
Rationale: The correct answer is C: An absence of blood in stool. This suggests Crohn's disease over ulcerative colitis because Crohn's can involve any part of the GI tract and may not always present with blood in stool, in contrast to ulcerative colitis which typically involves the rectum and almost always presents with blood in stool due to continuous inflammation in the colon. Choices A, B, and D are more commonly associated with ulcerative colitis, which typically presents with a pattern of exacerbations and remissions, severe diarrhea, and rectal mucosal involvement.
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A client with a cold is taking the antitussive benzonatate (Tessalon). Which assessment data indicates to the nurse that the medication is effective?
- A. Reports reduced nasal discharge.
- B. Denies having coughing spells.
- C. Able to sleep through the night.
- D. Expectorating bronchial secretions.
Correct Answer: B
Rationale: The correct answer is B: Denies having coughing spells. Benzonatate is an antitussive medication that suppresses cough reflex. If the client denies having coughing spells, it indicates that the medication is effectively suppressing the cough. This is the most direct indicator of the medication's effectiveness.
A: Reports reduced nasal discharge - This is not directly related to the effectiveness of benzonatate in suppressing cough.
C: Able to sleep through the night - While improved sleep may result from reduced coughing, it is not as specific an indicator of antitussive effectiveness as denying coughing spells.
D: Expectorating bronchial secretions - This indicates productive coughing, which is not the intended effect of benzonatate.
A client with a diagnosis of schizophrenia is being treated with risperidone (Risperdal). Which finding should the nurse report to the healthcare provider immediately?
- A. Weight gain.
- B. Dry mouth.
- C. Muscle rigidity.
- D. Drowsiness.
Correct Answer: C
Rationale: The correct answer is C: Muscle rigidity. This finding could be indicative of Neuroleptic Malignant Syndrome (NMS), a rare but serious side effect of antipsychotic medications like risperidone. NMS is characterized by severe muscle rigidity, fever, altered mental status, and autonomic dysfunction. Prompt medical intervention is crucial to prevent complications.
A: Weight gain is a common side effect of risperidone and is typically not considered an urgent issue.
B: Dry mouth is a common side effect of risperidone and can be managed with oral hygiene measures.
D: Drowsiness is a common side effect of risperidone and may improve over time or with dosage adjustments. It is not typically an immediate concern unless severe or accompanied by other worrisome symptoms.
A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen therapy. Which instruction should the nurse provide?
- A. Use oxygen continuously, even while sleeping.
- B. Adjust the oxygen flow rate to 5 liters per minute if short of breath.
- C. Report any signs of difficulty breathing immediately.
- D. Take off the oxygen while eating or drinking.
Correct Answer: A
Rationale: The correct answer is A: Use oxygen continuously, even while sleeping. In COPD, maintaining consistent oxygen levels is crucial to prevent hypoxia. Oxygen therapy should be used continuously, including during sleep, to ensure adequate oxygenation. Using oxygen only when short of breath (Choice B) may lead to hypoxia during periods of rest. Reporting difficulty breathing (Choice C) is important but not specific to oxygen therapy. Taking off oxygen while eating or drinking (Choice D) can result in decreased oxygen levels, which can be dangerous for someone with COPD.
A client with a history of deep vein thrombosis (DVT) is receiving warfarin (Coumadin). Which laboratory value indicates a therapeutic effect of the medication?
- A. INR of 2.5.
- B. PTT of 45 seconds.
- C. Hemoglobin of 12 g/dL.
- D. Platelet count of 150,000/mm³.
Correct Answer: A
Rationale: The correct answer is A: INR of 2.5. INR (International Normalized Ratio) is used to monitor the effectiveness of warfarin therapy. A target INR range for DVT treatment is typically 2.0-3.0. An INR of 2.5 indicates that the client's blood is clotting within the desired therapeutic range, preventing excessive clotting while avoiding excessive bleeding.
B: PTT measures the effectiveness of heparin, not warfarin.
C: Hemoglobin level and D: Platelet count are not specific indicators of warfarin's therapeutic effect on clotting factors.
In summary, the correct answer A is the most relevant laboratory value for monitoring the therapeutic effect of warfarin in a client with DVT.
A 60-year-old man presents with fatigue, polyuria, and polydipsia. Laboratory tests reveal hyperglycemia and ketonuria. What is the most likely diagnosis?
- A. Type 1 diabetes mellitus
- B. Type 2 diabetes mellitus
- C. Diabetes insipidus
- D. Hyperthyroidism
Correct Answer: A
Rationale: The most likely diagnosis for a 60-year-old man with fatigue, polyuria, polydipsia, hyperglycemia, and ketonuria is Type 1 diabetes mellitus. The key clues are the presence of ketonuria, which indicates the body is breaking down fats for energy due to lack of insulin in Type 1 diabetes. Additionally, the acute onset of symptoms in an older individual suggests an autoimmune destruction of pancreatic beta cells seen in Type 1 diabetes. Type 2 diabetes is less likely due to the acute presentation and ketonuria. Diabetes insipidus presents with polyuria but not hyperglycemia or ketonuria. Hyperthyroidism typically presents with symptoms such as weight loss, tremors, and heat intolerance, not the classic symptoms seen in this case.