Nokea
An adult woman who has multiple sclerosis (MS) asks the nurse why she developed multiple sclerosis. What information should the nurse include when responding?
- A. MS usually follows a streptococcal infection.
- B. MS is an autoimmune condition.
- C. MS occurs more often among persons who have had chickenpox.
- D. MS may be related to mosquito bites.
Correct Answer: B
Rationale: Multiple sclerosis is an autoimmune disorder where the immune system attacks myelin in the central nervous system, unlike infections or mosquito bites.
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The nurse is caring for a newborn. Which of the following signs would indicate neonatal abstinence syndrome? Select all that apply.
- A. Irritability and restlessness
- B. Meconium ileus and floppy muscle tone
- C. Microcephaly and cleft palate
- D. Nasal congestion and frequent sneezing
- E. Poor feeding and loose stools
Correct Answer: A,D,E
Rationale: Neonatal abstinence syndrome includes irritability , nasal congestion and sneezing , and poor feeding with loose stools due to withdrawal. Meconium ileus and hypotonia suggest cystic fibrosis, and microcephaly and cleft palate are congenital anomalies.
The nurse is caring for a client with spontaneous rupture of membranes. The nurse notes a loop of umbilical cord protruding from the vagina. Which of the following actions should the nurse take?
- A. Apply suprapubic pressure
- B. Perform Leopold maneuvers
- C. Perform the McRoberts maneuver
- D. Assist the client to the knee-chest position
Correct Answer: D
Rationale: Umbilical cord prolapse is an emergency requiring the knee-chest position to relieve cord compression. Suprapubic pressure and McRoberts are for shoulder dystocia, and Leopold maneuvers are for fetal positioning assessment.
While sitting at the nurse's station, the nurse observes that a client uses a tissue to pick up magazines and change channels on the television. There has been no such behavior in the past. The nurse should:
- A. Talk with the client about the behavior.
- B. Provide the client with a pair of nonsterile gloves.
- C. Take the tissues away from the client.
- D. Recognize the behavior as a means of getting attention.
Correct Answer: A
Rationale: Talking with the client assesses potential obsessive-compulsive behavior or anxiety. Gloves or removing tissues may escalate distress. Attention-seeking is an assumption without evidence.
The nurse is speaking with the parent of a toddler who believes the child has a hearing deficit. Which findings support this suspected diagnosis? Select all that apply.
- A. Behavior appears withdrawn
- B. Inintelligible speech began at age 12 months
- C. Monotone speech
- D. Seems attentive, nods, and smiles when given directions
- E. Speaks with a loud voice
Correct Answer: A,C,E
Rationale: Signs of hearing deficit in a toddler include withdrawn behavior , monotone speech , and loud speech due to inability to modulate voice. Inintelligible speech at 12 months is normal, and attentiveness suggests intact hearing.
The nurse is talking with a client who has a new prescription for metronidazole. Which of the following statements by the client would require follow up?
- A. I can continue to drink a glass of wine with dinner while I am taking this medication'
- B. I might experience a metallic taste in my mouth while I am taking this medication'
- C. I should not be concerned if my urine turns a dark color while taking this medication'
- D. I will immediately contact my health care provider if I experience a rash or skin peeling.'
Correct Answer: A
Rationale: Drinking alcohol while taking metronidazole can cause a disulfiram-like reaction, requiring follow-up. Metallic taste and dark urine are common side effects, and reporting rash or peeling is appropriate.