Nokea
During history taking of a client admitted with newly diagnosed Hodgkin's disease, which symptom should the nurse expect the client to report?
- A. Weight gain
- B. Night sweats
- C. Severe lymph node pain
- D. Headache with minor visual changes
Correct Answer: B
Rationale: Assessment of a client with Hodgkin's disease most often reveals night sweats; enlarged, painless lymph nodes; fever; and malaise. Weight loss may be present if metastatic disease occurs. Headache and visual changes may occur if brain metastasis is present.
You may also like to solve these questions
A preschooler with a history of cleft palate repair comes to the clinic for a routine well-child checkup. To determine whether this child is experiencing a long-term effect of cleft palate, which question should the nurse ask the parent?
- A. Does the child play with an imaginary friend?
- B. Was the child recently treated for pneumonia?
- C. Does the child respond when called by name?
- D. Has the child had any difficulty swallowing food?
Correct Answer: C
Rationale: A child with cleft palate is at risk for developing frequent otitis media, which can result in hearing loss. Unresponsiveness may be an indication that the child is experiencing hearing loss. Option 1 is normal behavior for a preschool child. Many preschoolers with vivid imaginations have imaginary friends. Options 2 and 4 are unrelated to cleft palate after repair.
A client seeks treatment in an ambulatory clinic for hoarseness that has persisted for 8 weeks. Based on the symptom, the nurse interprets that the client is at risk for which disorder?
- A. Thyroid cancer
- B. Acute laryngitis
- C. Laryngeal cancer
- D. Bronchogenic cancer
Correct Answer: C
Rationale: Hoarseness is a common early sign of laryngeal cancer, but not of thyroid or bronchogenic cancer. Hoarseness that persists for 8 weeks is not associated with an acute problem, such as laryngitis.
The nurse is performing an admission assessment on a client admitted with a diagnosis of Raynaud's disease. The nurse assesses for the associated symptoms by performing which actions?
- A. Checking for a rash on the digits
- B. Observing for softening of the nails or nail beds
- C. Palpating for a rapid or irregular peripheral pulse
- D. Palpating for diminished or absent peripheral pulses
Correct Answer: D
Rationale: Raynaud's disease is vasospasm of the arterioles and arteries of the upper and lower extremities. It produces closure of the small arteries in the distal extremities in response to cold, vibration, or external stimuli. Palpation for diminished or absent peripheral pulses checks for interruption of circulation. Skin changes include hair loss, thinning or tightening of the skin, and delayed healing of cuts or injuries. A rash on the digits is not a characteristic of this disorder. The nails grow slowly become brittle or deformed, and heal poorly around the nail beds when infected. Although palpation of peripheral pulses is correct, a rapid or irregular pulse would not be noted.
A client diagnosed with myasthenia gravis is experiencing prolonged periods of weakness, and the primary health care provider prescribes an edrophonium test, also known as a Tensilon test. A test dose is administered and the client becomes weaker. How should the nurse interpret these results?
- A. Myasthenic crisis is present.
- B. Cholinergic crisis is present.
- C. This result is a normal finding.
- D. This result is a positive finding.
Correct Answer: B
Rationale: An edrophonium test may be performed to determine whether increasing weakness in a client with previously diagnosed myasthenic is a result of cholinergic crisis (overmedication) with anticholinesterase medications or myasthenic crisis (undermedication). Worsening of the symptoms after the test dose of medication is administered indicates a cholinergic crisis.
The nurse suspects that an air embolism has occurred when the client's central venous catheter disconnects from the intravenous (IV) tubing. The nurse immediately places the client on her or his left side in which position?
- A. High Fowler's
- B. Trendelenburg's
- C. Lateral recumbent
- D. Reverse Trendelenburg's
Correct Answer: B
Rationale: If the client develops an air embolism, the immediate action is to place the client in Trendelenburg's position on the left side. This position raises the client's feet higher than the head and traps any air in the right atrium. If necessary, the air can then be directly removed by intracardiac aspiration.