Nokea
On an assessment of a client's mouth, the nurse notices white patches on the buccal mucosa. The nurse tries to obtain a sample for a culture, but the lesion cannot be rubbed off. The nurse would suspect that this lesion is:
- A. Xerostomia
- B. Candidiasis
- C. Leukoplakia
- D. Stomatitis
Correct Answer: C
Rationale: Leukoplakia cannot be rubbed off.
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A mother brings her 3-year-old child who is unconscious but breathing to the ER with an apparent drug overdose. The mother found an empty bottle of aspirin next to her child in the bathroom. Which nursing action is the most appropriate?
- A. Put in a nasogastric tube and lavage the child's stomach.
- B. Monitor muscular status.
- C. Teach mother poison prevention techniques.
- D. Place child on respiratory assistance.
Correct Answer: A
Rationale: The immediate treatment for drug overdose is removal of the drug from the stomach by either forced emesis or gastric lavage. The child's unconscious state prohibits forced emesis. Toxic amounts of salicylates directly affect the respiratory system, which could lead to respiratory failure. The mother's anxiety is probably so high that preventive guidance will be ineffective. Respiratory assistance is not needed if the child's respiratory function is unaltered.
A client with a history of ovarian cancer is admitted with complaints of abdominal swelling. The nurse should give priority to:
- A. Monitoring for ascites
- B. Administering pain medication
- C. Monitoring blood pressure
- D. Administering chemotherapy
Correct Answer: A
Rationale: Abdominal swelling in ovarian cancer often indicates ascites, so monitoring for ascites is the priority to guide treatment.
The nurse is assessing a client upon arrival to the emergency department. Partial airway obstruction is suspected. Which clinical manifestation is a late sign of airway obstruction?
- A. Rales in lungs
- B. Restless behavior
- C. Cyanotic ear lobes
- D. Inspiratory stridor
Correct Answer: C
Rationale: Cyanotic ear lobes are a late sign of airway obstruction, indicating severe hypoxia. Rales (A) suggest fluid, restlessness (B) is early, and stridor (D) is an earlier obstructive sign.
A client has been admitted to the labor and delivery unit in active labor. After assessing her, the RN notes that the client's fetus position is left occipital posterior. Which of the following statements best describes what this means to the labor process:
- A. Decreases the overall time of the labor process
- B. Prolongs the client's first stage of labor
- C. Decreases the time of the client's first stage of labor
- D. Prolongs the client's third stage of labor
Correct Answer: B
Rationale: The left occipital posterior position presents a larger fetal head diameter, increasing pressure on sacral nerves and prolonging the first stage of labor due to slower fetal descent.
A client with a history of chronic migraines is admitted with complaints of photophobia. The nurse should give priority to:
- A. Providing a dark environment
- B. Administering pain medication
- C. Monitoring blood pressure
- D. Administering oxygen
Correct Answer: A
Rationale: A dark environment reduces photophobia in migraines, improving comfort and reducing symptom severity.