Nokea
A college student who is diagnosed as having infectious mononucleosis asks how the disease is spread. The nurse's response is based on the knowledge that the usual mode of transmission is through:
- A. skin.
- B. genital contact.
- C. contaminated water.
- D. intimate oral contact.
Correct Answer: D
Rationale: Infectious mononucleosis, known as the 'kissing disease,' is spread through intimate oral contact, such as kissing or sharing utensils.
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The client is diagnosed with polycythemia vera. The nurse would prepare to perform which intervention?
- A. Type and crossmatch for a transfusion.
- B. Assess for petechiae and purpura.
- C. Perform phlebotomy of 500 mL of blood.
- D. Monitor for low hemoglobin and hematocrit.
Correct Answer: C
Rationale: Polycythemia vera requires phlebotomy (C) to reduce blood viscosity. Transfusions (A) worsen hyperviscosity, petechiae (B) are for thrombocytopenia, and Hb/Hct (D) are elevated.
The nurse knows that infectious mononucleosis is caused by which of the following?
- A. Cytomegalovirus
- B. Beta-hemolytic Streptococcus
- C. Epstein-Barr virus
- D. Herpes simplex virus I
Correct Answer: C
Rationale: Infectious mononucleosis is caused by the Epstein-Barr virus.
The client diagnosed with atrial fibrillation is admitted with warfarin (Coumadin) toxicity. Which HCP order would the nurse anticipate?
- A. Protamine sulfate, an anticoagulant antidote.
- B. Heparin sodium, an anticoagulant.
- C. Lovenox, a low molecular weight anticoagulant.
- D. Vitamin K, an anticoagulant agonist.
Correct Answer: D
Rationale: Warfarin toxicity causes bleeding; vitamin K (D) reverses it. Protamine (A) reverses heparin, heparin/Lovenox (B, C) worsen bleeding.
The client diagnosed with sickle cell anemia is experiencing a vaso-occlusive sickle cell crisis secondary to an infection. Which medical treatment should the nurse anticipate the HCP ordering for the client?
- A. Administer meperidine (Demerol) intravenously.
- B. Admit the client to a private room and keep in reverse isolation.
- C. Infuse D5W 0.33% NS at 150 mL/hr via pump.
- D. Insert a 22-French Foley catheter with a urimeter.
Correct Answer: C
Rationale: Hydration with IV fluids (C) prevents sickling in vaso-occlusive crisis. Meperidine (A) is avoided (risks seizures), isolation (B) is excessive, and Foley (D) is unnecessary.
The nurse is caring for a client who is thought to have pernicious anemia. What signs and symptoms would the nurse expect in this person?
- A. Easy bruising
- B. Beefy-red tongue
- C. Fine red rash on the extremities
- D. Pruritus
Correct Answer: B
Rationale: A beefy-red tongue is a hallmark symptom of pernicious anemia due to vitamin B12 deficiency.