Nokea
A healthcare worker with no known exposure to tuberculosis has received a Mantoux tuberculosis skin test. The nurse's assessment of the test after 62 hours indicates 5 mm of erythema without induration. What is the best initial nursing action?
- A. Document negative results in the client's medical record
- B. Repeat the test immediately on the opposite forearm
- C. Notify the healthcare provider for further evaluation
- D. Schedule the worker for a chest X-ray
Correct Answer: A
Rationale: Erythema without induration is not considered a positive result. Documentation of negative findings is appropriate.
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Mechanisms of dyspnea in left heart disease include all, except
- A. PVH and decreased lung compliance
- B. Respiratory muscle fatigue
- C. Elevated LV End diastolic pressure leads to decreased antegrade coronary blood flow
- D. Reverse 'Bernheim' effect
Correct Answer: C
Rationale: Elevated LV end-diastolic pressure does not typically lead to decreased antegrade coronary blood flow.
Which therapeutic management should the nurse expect to implement for a child with rheumatic fever?
- A. Administering penicillin
- B. Avoiding salicylates (aspirin)
- C. Imposing strict bed rest for 4 to 6 weeks
- D. Administering corticosteroids if chorea develops
Correct Answer: A
Rationale: The goal of medical management is the eradication of the hemolytic streptococci. Penicillin is the drug of choice. Salicylates can be used to control the inflammatory process, especially in the joints, and reduce the fever and discomfort. Bed rest is recommended for the acute febrile stage, but it does not need to be strict. The chorea is transient and will resolve without treatment.
The mother of a toddler reports that the child's father has just had a myocardial infarction (MI). Because of this, the nurse recommends the child have a(n):
- A. Electrocardiogram
- B. Lipid profile
- C. Echocardiogram
- D. Cardiac catheterization
Correct Answer: B
Rationale: Current recommendations are for a lipid profile in children over 2 years of age who have a family history of cardiac events or high cholesterol.
A male client in skeletal traction tells the nurse that he is frustrated because he needs help repositioning himself in bed. Which intervention should the nurse implement?
- A. Provide an overhead trapeze to the bed for the client to use
- B. Assist the client with repositioning every hour to prevent discomfort.
- C. Encourage the client to use a bedpan instead of getting up to the bathroom.
- D. Offer additional pain medication to help the client relax.
Correct Answer: A
Rationale: An overhead trapeze allows the client to reposition independently, promoting autonomy and reducing frustration.
A client with carcinoma of the lung is complaining of weakness and has a serum sodium level of 117 mEq/L. Which nursing problem should the nurse include in this client's plan of care?
- A. Altered urinary elimination
- B. Impaired gas exchange
- C. Fluid volume excess
- D. Decreased cardiac output
Correct Answer: C
Rationale: Hyponatremia (low sodium level) is often associated with fluid volume excess in clients with lung carcinoma.