Nokea
An elderly client has a 17-mm induration after a tuberculin skin test. Based on this result, which statement is most accurate?
- A. The client has a false-positive reaction due to advanced age
- B. The client has a tuberculosis infection
- C. The client has active tuberculosis disease
- D. The client must be isolated immediately
Correct Answer: B
Rationale: A 17-mm induration in an elderly client indicates TB infection, as the threshold is ≥10 mm for high-risk groups. It doesn't confirm active disease, which requires further testing (e.g., chest X-ray). False positives are possible but not assumed based on age alone. Isolation isn't required without active disease.
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Which finding is commonly noted in the client with bladder cancer?
- A. Painless hematuria.
- B. Bladder spasms.
- C. Lower back pain.
- D. Urinary frequency.
Correct Answer: A
Rationale: Painless hematuria is a hallmark symptom of bladder cancer, often the earliest sign. Other symptoms may occur but are less specific.
The nurse's neighbor has a total cholesterol of 450 mg/dL. The neighbor asks the nurse what this means. What should the nurse include when responding?
- A. The cholesterol level is slightly high, but exercise and a low-fat diet should reduce it to normal.
- B. The cholesterol level is below normal levels, but this is good.
- C. The cholesterol level is high. The neighbor should talk with the physician about ways to lower it.
- D. The cholesterol is within normal limits.
Correct Answer: C
Rationale: A cholesterol level of 450 mg/dL is significantly elevated, increasing cardiovascular risk, requiring medical consultation.
The nurse, assisting in applying a cast to a client with a broken arm, knows that the
- A. Cast material should be dipped several times into the warm water
- B. Cast should be covered until it dries
- C. Wet cast should be handled with the palms of hands
- D. Casted extremity should be placed on a cloth-covered surface
Correct Answer: C
Rationale: Wet cast should be handled with the palms of hands. This prevents damage to the cast and ensures proper setting.
A client with type 2 diabetes, coronary artery disease, and peripheral arterial disease developed hospital-acquired pneumonia (HAP) and has been receiving intravenous (IV) antibiotics for 4 days. Which parameter monitored by the nurse best indicates the effectiveness of treatment?
- A. Color of sputum
- B. Lung sounds
- C. Saturation level
- D. White blood cell count (WBC)
Correct Answer: D
Rationale: A decreasing WBC count indicates resolving infection, as HAP elevates WBCs. Sputum color is unreliable, lung sounds improve later, and oxygen saturation reflects oxygenation, not infection status.
The nurse is caring for a client with trigeminal neuralgia (tic douloureux). To assist the client with nutrition needs, the nurse should
- A. Offer small meals of high calorie soft food
- B. Assist the client to sit in a chair for meals
- C. Provide additional servings of fruits and raw vegetables
- D. Encourage the client to eat fish, liver and chicken
Correct Answer: A
Rationale: Offer small meals of high calorie soft food. High-calorie soft foods minimize chewing, providing nourishment with less pain.