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A newborn infant is diagnosed with imperforate anus. Which description of this disorder should the nurse provide to the parents?
- A. The presence of fecal incontinence
- B. Incomplete development of the anus
- C. The infrequent and difficult passage of dry stools
- D. Invagination of a section of the intestine into the distal bowel
Correct Answer: B
Rationale: Imperforate anus (anal atresia, anal agenesis) is the incomplete development or absence of the anus in its normal position in the perineum. Option 1 describes encopresis. Encopresis generally affects preschool and school-age children. Option 3 describes constipation. Constipation can affect any child at any time, although it peaks at age 2 to 3 years. Option 4 describes intussusception.
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The nurse is caring for a client with a history of multiple sclerosis. Which of the following interventions should be included in the plan of care?
- A. Encourage daily exercise.
- B. Limit fluid intake.
- C. Provide a high-fat diet.
- D. Restrict social activities.
Correct Answer: A
Rationale: Daily exercise helps maintain mobility and strength in multiple sclerosis.
The nurse is counseling a client regarding treatment of the client's newly diagnosed depression. The nurse emphasizes that full benefit from antidepressant therapy usually takes how long?
- A. 1 week
- B. 2 to 4 weeks
- C. 5 to 7 weeks
- D. 8 weeks
Correct Answer: B
Rationale: Antidepressants typically take 2 to 4 weeks to achieve full therapeutic effect, as they require time to adjust neurotransmitter levels. Other timeframes are too short or overly prolonged.
A client with a history of liver failure is admitted with hepatic encephalopathy. The nurse should monitor the client for which of the following?
- A. Asterixis.
- B. Hypotension.
- C. Polyuria.
- D. Bradycardia.
Correct Answer: A
Rationale: Asterixis (flapping tremor) is a hallmark sign of hepatic encephalopathy due to ammonia buildup.
The nurse is caring for a client in labor who has butorphanol tartrate prescribed for the relief of labor pain. During the administration of the medication, the nurse should ensure that which priority item is readily available?
- A. Naloxone
- B. Meperidine hydrochloride
- C. An intravenous form of an antiemetic
- D. An intravenous solution of normal saline
Correct Answer: A
Rationale: Butorphanol tartrate is an opioid analgesic that provides systemic pain relief during labor. The nurse should ensure that naloxone and resuscitation equipment are readily available to treat respiratory depression, should it occur. Meperidine hydrochloride is also an opioid analgesic that may be used for pain relief, but it also causes respiratory depression. Although an antiemetic may be prescribed for vomiting, antiemetics may enhance the respiratory depressant effects of the butorphanol tartrate. Although an IV access is desirable, the administration of normal saline is unrelated to the administration of this medication.
A client with a history of heart failure is prescribed spironolactone (Aldactone). The nurse should monitor the client for which of the following electrolyte imbalances?
- A. Hyperkalemia.
- B. Hypocalcemia.
- C. Hyponatremia.
- D. Hypermagnesemia.
Correct Answer: A
Rationale: Spironolactone, a potassium-sparing diuretic, can cause hyperkalemia, requiring monitoring.