Nokea
During the check up of a 2 month-old infant at a well baby clinic, the mother expresses concern to the nurse because a flat pink birthmark on the baby's forehead and eyelid has not gone away. What is an appropriate response by the nurse?
- A. Mongolian spots are a normal finding in dark-skinned children.'
- B. Port wine stains are often associated with other malformations.'
- C. Telangiectatic nevi are normal and will disappear as the baby grows.'
- D. The child is too young for consideration of surgical removal of these at this time.'
Correct Answer: C
Rationale: Telangiectatic nevi, salmon patch or stork bite birthmarks, are a normal variation and the facial nevi will generally disappear by ages 1 to 2 years.
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A client is admitted with rheumatoid arthritis. Which symptoms, if exhibited by the client, are most consistent with the admitting diagnosis?
- A. A 72-year-old with pain, redness, and swelling in the big toes
- B. A 68-year-old with enlarged finger joints and pain in the knees
- C. A 34-year-old with joint pains and a red rash on the cheeks
- D. A 28-year-old with enlarged joints and painful muscles
Correct Answer: B
Rationale: Rheumatoid arthritis causes symmetrical joint inflammation, leading to enlarged, painful joints like fingers and knees. Toe pain suggests gout, rash suggests lupus, and muscle pain is less specific.
An adult is admitted to the emergency room with a laceration on the forearm and BP=140/74, P=110, and R=36. The client also.adult is admitted to the emergency room with a laceration on the forearm and BP=140/74, P=110, and R=36. The client also complains of tingling around the mouth and in the fingers and toes. What should the nurse expect to do initially?
- A. Administer oxygen
- B. Have the client breathe into a paper bag
- C. Call the physician immediately
- D. Encourage the client to do deep breathing exercises
Correct Answer: B
Rationale: Tachypnea and tingling suggest hyperventilation causing respiratory alkalosis; breathing into a paper bag restores CO2 levels, correcting pH.
When caring for a client with myasthenia gravis, an important nursing consideration would be to
- A. prevent accidents from falls as a result of vertigo.
- B. maintain fluid and electrolyte balance.
- C. control situations that could increase intracranial pressure and cerebral edema.
- D. assess muscle groups toward the end of the day.
Correct Answer: D
Rationale: client has increased muscle fatigue, needs more assistance toward end of day
The treatment protocol for a client with acute lymphatic leukemia includes Orasone (prednisone), Trexall (methotrexate), and Zantac (ranitidine). The purpose of Zantac is to:
- A. Decrease the secretion of pancreatic enzymes.
- B. Enhance the effectiveness of the methotrexate.
- C. Promote peristalsis.
- D. Prevent a common side effect of prednisone.
Correct Answer: D
Rationale: Zantac (ranitidine) prevents gastric irritation and ulcers, a common side effect of prednisone. It does not affect pancreatic enzymes, methotrexate efficacy, or peristalsis.
The nurse is providing instructions for a client with asthma who is sensitive to house dust-mites. Which information about prevention of asthma episodes would be the most helpful to include during the teaching?
- A. Change the pillow covers every month
- B. Wash bed linens in warm water with a cold rinse
- C. Wash and rinse the bed linens in hot water
- D. Use air filters in the furnace system
Correct Answer: C
Rationale: Wash and rinse the bed linens in hot water. For asthma clients sensitive to house dust-mites, washing bed linens in hot water above 130 degrees Fahrenheit is necessary to kill dust-mites.