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A nurse is caring for a client who suspects recent exposure to inhalation anthrax. Which of the following findings indicate possible exposure?
- A. Vesicles on the skin
- B. Respiratory failure
- C. Flu-like symptoms
- D. Coughing of blood
Correct Answer: B
Rationale: The correct answer is B: Respiratory failure. Inhalation anthrax primarily affects the respiratory system, causing symptoms such as difficulty breathing, cough, and chest discomfort. Respiratory failure can occur in severe cases. Vesicles on the skin (A) are not typically associated with inhalation anthrax. Flu-like symptoms (C) are nonspecific and can be seen with various infections. Coughing of blood (D) is not a common symptom of inhalation anthrax. Therefore, the most indicative finding of possible exposure to inhalation anthrax is respiratory failure.
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A nurse is caring for a child who is admitted with suspected acute appendicitis. Which of the following manifestations should indicate to the nurse that the child’s appendix is perforated?
- A. Sudden decrease in abdominal pain.
- B. Absence of Rovsing’s sign.
- C. Low-grade fever.
- D. Rigid abdomen.
Correct Answer: A
Rationale: The correct answer is A: Sudden decrease in abdominal pain. A sudden decrease in abdominal pain can indicate a perforated appendix due to the release of pressure and inflammation. This sudden relief occurs when the appendix ruptures, causing the abdominal pain to subside temporarily. This is a critical sign that the appendix has perforated and requires immediate medical attention. The other choices are incorrect because: B: Absence of Rovsing’s sign is not specific to a perforated appendix. C: Low-grade fever is commonly seen in uncomplicated appendicitis and may not necessarily indicate perforation. D: A rigid abdomen is a sign of peritonitis, which can occur with a perforated appendix, but it is not as specific as the sudden decrease in pain.
A home health nurse is assessing an older adult client in the home who has decreased vision due to a history of glaucoma. Which of the following findings should the nurse identify as a safety risk?
- A. Handrails are present in the bathroom.
- B. Electrical cords are placed along the walls.
- C. Uses a microwave for cooking.
- D. Scatter rugs are present in the kitchen.
Correct Answer: D
Rationale: The correct answer is D: Scatter rugs are present in the kitchen. Scatter rugs can pose a safety risk for an older adult with decreased vision due to glaucoma as they increase the risk of tripping and falling. The uneven surface and lack of secure placement make scatter rugs hazardous. Handrails in the bathroom (A) enhance safety, electrical cords along the walls (B) may be a tripping hazard but can be easily addressed, and using a microwave for cooking (C) is a safe and convenient option for someone with decreased vision.
A nurse is attending a social event when another guest coughs weakly once, grasps his throat, and cannot talk. Which of the following actions should the nurse take?
- A. Perform the Heimlich maneuver.
- B. Slap the client on the back several times.
- C. Assist the client to the floor and begin mouth-to-mouth resuscitation.
- D. Observe the client before taking further action.
Correct Answer: A
Rationale: The correct answer is A: Perform the Heimlich maneuver. This action is appropriate for a choking individual who is unable to speak, cough weakly, and grasp their throat, indicating a partial airway obstruction. The Heimlich maneuver is designed to dislodge the obstruction by applying abdominal thrusts. This is the most effective intervention in this scenario to clear the airway and restore breathing. Slapping the client on the back (B) may not effectively remove the obstruction. Mouth-to-mouth resuscitation (C) is not indicated for a conscious choking person. Observing the client (D) without taking immediate action can lead to a worsening situation.
A nurse is caring for a client who has prostate cancer. The nurse should expect the provider to prescribe which of the following medications for this client?
- A. Tamoxifen
- B. Leuprolide
- C. Finasteride
- D. Cyclophosphamide
Correct Answer: B
Rationale: The correct answer is B: Leuprolide. Leuprolide is a gonadotropin-releasing hormone agonist that suppresses testosterone production, which can help slow the growth of prostate cancer. Tamoxifen (A) is used for breast cancer, Finasteride (C) is used for benign prostatic hyperplasia, and Cyclophosphamide (D) is a chemotherapy drug for various cancers. Therefore, in this case, the most appropriate medication for prostate cancer would be Leuprolide (B).
A nurse is assessing a client who has diabetes insipidus. Which of the following findings should the nurse expect?
- A. Bradycardia
- B. Hyperglycemia
- C. Dehydration
- D. Polyphagia
Correct Answer: C
Rationale: The correct answer is C: Dehydration. In diabetes insipidus, there is a deficiency of antidiuretic hormone leading to excessive urine output, causing dehydration. Bradycardia (A) is not typically associated. Hyperglycemia (B) is seen in diabetes mellitus, not diabetes insipidus. Polyphagia (D) is excessive hunger, which is not a common symptom of diabetes insipidus.