Nokea
An adolescent tells the school nurse she thinks she has infectious mononucleosis. The nurse should next assess the client for?
- A. Sore throat and malaise.
- B. Fatigue and weight loss.
- C. Coldlike symptoms and fever.
- D. Skin rash and abdominal pain.
Correct Answer: A
Rationale: Sore throat and malaise are hallmark symptoms of mononucleosis, requiring targeted assessment.
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The nurse is caring for a client with a closed head injury. Which finding indicates increasing intracranial pressure?
- A. Widening pulse pressure
- B. Tachycardia
- C. Hyperthermia
- D. Hypotension
Correct Answer: A
Rationale: Widening pulse pressure (e.g., increasing systolic with stable diastolic) is a sign of increasing intracranial pressure, part of Cushing's triad.
A client with a history of type 2 diabetes is prescribed glipizide (Glucotrol). The nurse should instruct the client to:
- A. Take the medication 30 minutes before meals.
- B. Avoid alcohol consumption.
- C. Take the medication at bedtime.
- D. Stop the medication if blood glucose normalizes.
Correct Answer: A, B
Rationale: Glipizide should be taken 30 minutes before meals to optimize glucose control, and alcohol should be avoided to prevent hypoglycemia.
A client with a history of schizophrenia is prescribed aripiprazole (Abilify). The nurse should monitor the client for which of the following adverse effects?
- A. Akathisia.
- B. Hypoglycemia.
- C. Bradycardia.
- D. Hypotension.
Correct Answer: A
Rationale: Aripiprazole can cause akathisia, a movement disorder, requiring monitoring.
While assessing a term neonate on a home visit to a primiparous client 2 weeks after a vaginal delivery, the nurse observes that the neonate is slightly jaundiced and the stool is a pale, light color. The nurse notifies the physician because these findings indicate which of the following?
- A. Biliary atresia.
- B. Rh isoimmunization.
- C. ABO incompatibility.
- D. Esophageal varices.
Correct Answer: A
Rationale: Pale stools and jaundice in a neonate suggest biliary atresia, a condition requiring urgent evaluation.
The nurse is assessing a client with a suspected cholecystitis. Which of the following findings is most indicative of this condition?
- A. Right upper quadrant pain.
- B. Left lower quadrant pain.
- C. Soft, nontender abdomen.
- D. Frequent loose stools.
Correct Answer: A
Rationale: Right upper quadrant pain is a hallmark sign of cholecystitis due to gallbladder inflammation.