Nokea
The client admitted with full-thickness burns may be developing DIC. Which signs/symptoms would support the diagnosis of DIC?
- A. Oozing blood from the IV catheter site.
- B. Sudden onset of chest pain and frothy sputum.
- C. Foul-smelling, concentrated urine.
- D. A reddened, inflamed central line catheter site.
Correct Answer: A
Rationale: DIC causes uncontrolled bleeding; oozing from IV sites (A) is a hallmark. Chest pain/sputum (B) suggests PE, urine odor (C) is unrelated, and redness (D) indicates infection.
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The nurse has been teaching the parents of a child with hemophilia about the care he will need. Which statement by the parents indicates a need for more instruction?
- A. If my child needs something for pain or a fever, I will give him acetaminophen instead of aspirin.'
- B. I will take my child to the dentist for regular checkups.'
- C. I will keep my child in the house most of the time.'
- D. My son's Medic Alert Bracelet arrived.'
Correct Answer: C
Rationale: Overprotecting the child by keeping him indoors most of the time prevents normal development. Acetaminophen, dental care, and a Medic Alert bracelet are appropriate.
The nurse is admitting a client with a diagnosis of rule-out Hodgkin's lymphoma. Which assessment data support this diagnosis?
- A. Night sweats and fever without 'chills.'
- B. Edematous lymph nodes in the groin.
- C. Malaise and complaints of an upset stomach.
- D. Pain in the neck area after a fatty meal.
Correct Answer: A
Rationale: Night sweats and fever (A) are classic Hodgkin’s B symptoms. Edematous nodes (B) are not typical (firm, non-tender), malaise/stomach (C) is nonspecific, and neck pain (D) suggests gallbladder issues.
The client who was recently admitted with gastric cancer appears pale and weak and states feeling fatigued. In reviewing the client’s laboratory results, which component of the CBC should the nurse most associate with the client’s gastric cancer and identify as the causative factor for the fatigue?
- A. White blood cell 12,200/mm3
- B. Hemoglobin 7.9 g/dL
- C. Serum protein 5.9 g/dL
- D. Blood urea nitrogen 22 mg/dL
Correct Answer: B
Rationale: A. The elevation in the WBC (normal is 4500–10,000/mm3 or microL) is concerning because it could indicate an infection, but the elevation would not necessarily be related to the gastric cancer. B. The presenting symptoms are indicative of anemia, which is common in gastric cancer due to chronic blood loss, or as a result of pernicious anemia (due to loss of intrinsic factor). The low Hgb (normal is 12–15 g/dL) may be the causative factor for the fatigue. C. The serum protein is slightly low (normal is 6.0–8.0 g/dL) and could be indicative of nutritional problems associated with the gastric cancer, but it is not specific to the signs and symptoms described in the question, and it is not part of a CBC. D. The BUN (normal is 5–25 mg/dL) is within normal parameters and is measuring kidney function or hydration status. It is not part of the CBC.
A 19-year-old college student reports to the health service with a sore throat, malaise, and fever of four days in duration. Examination shows cervical lymphadenopathy and splenomegaly. Temperature is 103°F. Blood is positive for heterophil antibody agglutination test. Which condition does the nurse expect this student to have?
- A. Streptococcal sore throat
- B. Infectious mononucleosis
- C. Rubella
- D. Influenza
Correct Answer: B
Rationale: The symptoms and positive heterophil antibody test are diagnostic for infectious mononucleosis.
A coworker being oriented by another nurse states, “I’m confused; a physician told me that graft-versus-host disease (GVHD) symptoms were desirable for a particular client after a bone marrow transplant.” Which should be the nurse’s best response?
- A. “GVHD isn’t desirable. Maybe you heard the physician wrong.”
- B. “That’s interesting. Did the client have a gastrointestinal tumor?”
- C. “That’s right if the transplant involved using autologous stem cells.”
- D. “GVHD is sometimes desirable with a hematological malignancy.”
Correct Answer: D
Rationale: A. GVHD is desirable if the primary source is hematological. B. Bone marrow transplant is not a treatment for GI malignancies unless the primary source is hematological. C. GVHD does not occur when a person receives autologous (his or her own) cells during a transplant. D. GVHD is sometimes desirable with a hematological malignancy. The donor lymphocytes can mount a reaction against any lingering tumor cells and destroy them.