Nokea
In planning daily care for a client with multiple sclerosis, the nurse would take into consideration that multiple sclerosis:
- A. Becomes progressively debilitating without remission
- B. Has unpredictable remissions and exacerbations
- C. Is rapidly fatal
- D. Responds quickly to antimicrobial therapy
Correct Answer: B
Rationale: Multiple sclerosis eventually becomes debilitating, but it is characterized by remission of symptoms. Remissions and exacerbations are unpredictable with multiple sclerosis. The client experiences progressive dysfunction after each exacerbation episode. Multiple sclerosis is usually slowly progressive. Multiple sclerosis is an autoimmune disease. Antimicrobial therapy has no effect on its course.
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A 9-month-old infant was diagnosed with nonorganic failure to thrive. During her hospitalization, primary nurses were assigned to initiate all infant feedings. The infant's parents question why they cannot feed their own child. Which of the following responses would be most appropriate by the nurse?
- A. By assigning the same nurses to the child, the nurses can begin to learn the infant's cues and feeding behaviors.
- B. The same nurses will prevent parental fatigue and frustration.
- C. The same nurses will prevent infant fatigue and frustration.
- D. Primary nurses will ensure privacy.
Correct Answer: A
Rationale: Consistent primary care nurses can better interpret infant cues and note feeding behaviors, which is critical in managing nonorganic failure to thrive.
The nurse is caring for a client with a head injury who has an intracranial pressure monitor in place. Assessment reveals an ICP reading of 66. What is the nurse's best action?
- A. Notify the physician.
- B. Record the reading as the only action.
- C. Turn the client and recheck the reading.
- D. Place the client supine.
Correct Answer: A
Rationale: An ICP of 66 mmHg is dangerously high (normal <20 mmHg), requiring immediate physician notification for intervention. Recording only (B), turning (C), or supine positioning (D) delays critical action.
Which of the following is an adverse effect associated with the use of Adriamycin (doxorubicin)?
- A. Ventricular arrhythmias
- B. Alopecia
- C. Leukopenia
- D. Stomatitis
Correct Answer: B
Rationale: Alopecia (hair loss) is a common adverse effect of doxorubicin, a chemotherapeutic agent, due to its impact on rapidly dividing cells, including hair follicles.
Which of the following side effects is associated with androgen therapy?
- A. Gynecomastia
- B. Increased appetite
- C. Virilization
- D. Euphoria
Correct Answer: C
Rationale: Androgen therapy promotes male secondary sexual characteristics leading to virilization (e.g. deepened voice facial hair). Gynecomastia is associated with estrogen and increased appetite or euphoria are not typical side effects of androgens.
The nurse is preparing to administer a dose of enoxaparin (Lovenox) to a client. Which injection site is most appropriate?
- A. Deltoid muscle
- B. Ventrogluteal muscle
- C. Anterolateral thigh
- D. Abdomen, 2 inches from the umbilicus
Correct Answer: D
Rationale: Enoxaparin, a low-molecular-weight heparin, is administered subcutaneously in the abdomen, 2 inches from the umbilicus, to ensure consistent absorption and minimize bruising. Muscle injections are inappropriate.