Nokea
A nurse notices that a newborn has a swelling in the scrotum. The nurse should interpret this as indicative of hydrocele if which of the following occurs?
- A. The swollen bulge can be reduced.
- B. The increase in scrotal size is bilateral.
- C. The scrotal sac can be transilluminated.
- D. The bulge appears during crying.
Correct Answer: C
Rationale: Transillumination of the scrotal sac indicates fluid, characteristic of a hydrocele, a common newborn condition.
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A client with a history of cirrhosis is prescribed propranolol (Inderal). The nurse should monitor the client for which of the following therapeutic effects?
- A. Decreased portal hypertension.
- B. Increased blood glucose.
- C. Decreased ammonia levels.
- D. Increased platelet count.
Correct Answer: A
Rationale: Propranolol reduces portal hypertension by decreasing portal vein pressure in cirrhosis.
After several months of taking olanzapine (Zyprexa), the client reports that he is no longer hearing voices of any kind. Which of the following would confirm that the client is developing insight into his illness?
- A. That Zyprexa is the best medicine I have ever had.'
- B. I didn't realize how sick I could get from a chemical brain imbalance.'
- C. My mom is proud of me for staying on my medicines.'
- D. I think I may be able to get a little part-time job soon.'
Correct Answer: B
Rationale: Acknowledging a chemical brain imbalance shows insight into the biological basis of the illness, indicating understanding of the need for treatment.
The nurse is monitoring a client with a fracture to the left arm. Which sign observed by the nurse is consistent with impaired venous return in the area?
- A. Increasing edema
- B. Weakened distal pulse
- C. Pallor or blotchy cyanosis
- D. Continued pain despite medication
Correct Answer: A
Rationale: Impaired venous return is characterized by increasing edema. In the client with a fracture, this is most often prevented by elevating the limb. The other options identify signs of arterial damage, which can occur if the artery is contused, thrombosed, lacerated, or becomes spastic.
A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with pneumonia. The nurse should monitor the client for which of the following complications?
- A. Hypercapnia.
- B. Hypotension.
- C. Pulmonary edema.
- D. Metabolic alkalosis.
Correct Answer: A
Rationale: Clients with COPD are at risk for hypercapnia (elevated CO2 levels) during pneumonia due to impaired gas exchange, which can worsen respiratory distress.
A client newly diagnosed with angina pectoris has taken two sublingual nitroglycerin tablets for chest pain. The chest pain is relieved, but the client now reports a headache. The nurse interprets that this most likely represents which response?
- A. An early sign of medication tolerance
- B. An allergic reaction to the nitroglycerin
- C. An expected side effect of the medication
- D. A warning that the medication should not be used again
Correct Answer: C
Rationale: Headache is a frequent side effect of nitroglycerin, because of the vasodilating action of the medication. It usually diminishes in frequency as the client becomes accustomed to the medication and is effectively treated with acetaminophen. The other options are incorrect.