Nokea
An adult is being worked up for possible pulmonary tuberculosis. The nurse knows that which test is most conclusive for the diagnosis of tuberculosis?
- A. Intradermal skin test
- B. Chest x-ray
- C. Sputum examination
- D. Computed tomography (CT) scan
Correct Answer: C
Rationale: Sputum examination for acid-fast bacilli is the gold standard for confirming tuberculosis, unlike skin tests (screening), x-rays (supportive), or CT (non-specific).
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Which of these statements by the nurse is incorrect if the nurse has the goal to reinforce information about cancers to a group of young adults?
- A. You can reduce your risk of this serious type of stomach cancer by eating lots of fruits and vegetables, limiting all meat, and avoiding nitrate-containing foods.
- B. Prostate cancer is the most common cancer in American men with results to threaten sexuality and life.
- C. Colorectal cancer is the second-leading cause of cancer-related deaths in the United States.
- D. Lung cancer is the leading cause of cancer deaths in the United States. Yet it's the most preventable of all cancers.
Correct Answer: A
Rationale: It is recommended that only red meat be limited for the prevention of stomach cancer. All of the other statements offer correct information.
A two-year-old who is one-day postoperative.
The mother of a two-year-old who is one-day postoperative tells the nurse, 'My child is so restless and overactive.' The nurse should
- A. direct the LPN/LVN to obtain the child's vital signs.
- B. ask the mother if the child's sutures are still intact.
- C. tell the nursing assistant to take the child for a walk.
- D. check to see when the child last received pain medication.
Correct Answer: D
Rationale: Strategy: Answers are a mix of assessments and implementations. Does this situation require validation? Yes. Determine the best assessment. (1) no indication that there are any problems (2) passing the buck (3) implementation, should first assess (4) correct-young children typically become restless and overactive if in pain, grimacing, clenching teeth, rocking, and aggressive behavior may also be observed
A pregnant diabetic client, who is 37 weeks gestation, is scheduled for an amniocentesis. The client asks the nurse the purpose of the test. The nurse should explain that the primary reason for performing an amniocentesis is:
- A. To determine the effect of the diabetes on the fetus
- B. To estimate the skeletal age of the fetus
- C. To determine the fetal lung maturity
- D. To obtain information about aberrant fetal genes
Correct Answer: C
Rationale: At 37 weeks, amniocentesis primarily assesses fetal lung maturity via lecithin/sphingomyelin ratio, critical for delivery planning. Diabetes effects , skeletal age , and genetic issues are less common indications.
The nurse is teaching a woman the normal changes of pregnancy. Which statement by the woman indicates correct understanding?
- A. There is decreased oxygen consumption during pregnancy.'
- B. There is an increased rate of peristalsis in the GI tract.'
- C. I will have a 50% increase in blood volume.'
- D. My metabolic rate will decrease.'
Correct Answer: C
Rationale: Pregnancy increases blood volume by about 50% to support fetal circulation, a correct understanding. Oxygen consumption and metabolic rate increase, and peristalsis slows.
A client is being treated for paranoid schizophrenia. When the client became loud and boisterous, the nurse immediately placed him in seclusion as a precautionary measure. The client willingly complied. The nurse's action
- A. may result in charges of unlawful seclusion and restraint
- B. leaves the nurse vulnerable for charges of assault and battery
- C. was appropriate in view of a client history of violence
- D. was necessary to maintain the therapeutic milieu of the unit
Correct Answer: A
Rationale: Seclusion should only be used when there is an immediate threat of violence or threatening behavior toward the staff, the other clients, or the client himself.