Nokea
The nurse interprets that which observation is related to the dysfunction of cranial nerve III (oculomotor nerve)?
- A. Mild drowsiness
- B. Unilateral ptosis
- C. Diminished mental acuity
- D. Less frequent spontaneous speech
Correct Answer: B
Rationale: Ptosis of the eyelid is caused by pressure on and the dysfunction of cranial nerve III, the oculomotor nerve. The remaining options identify early signs of a deteriorating level of consciousness.
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The mother explains that after meals her infant has been vomiting, and now it is becoming more frequent and forceful. During the assessment, the nurse notes visible peristaltic waves moving from left to right across the infant's abdomen. On the basis of these findings, which condition should the nurse suspect?
- A. Colic
- B. Intussusception
- C. Congenital megacolon
- D. Hypertrophic pyloric stenosis
Correct Answer: D
Rationale: In pyloric stenosis, the vomitus contains sour, undigested food but no bile, the child is constipated, and visible peristaltic waves move from left to right across the abdomen. A movable, palpable, firm, olive-shaped mass in the right upper quadrant may be noted. Crying during the evening hours, appearing to be in pain, but eating well and gaining weight are clinical manifestations of colic. An infant who suddenly becomes pale, cries out, and draws the legs up to the chest is demonstrating physical signs of intussusception. Ribbon-like stool, bile-stained emesis, the absence of peristalsis, and abdominal distention are symptoms of congenital megacolon (Hirschsprung's disease).
Intravenous immune globulin (IVIG) therapy is prescribed for a child diagnosed with idiopathic thrombocytopenic purpura (ITP). What are the expected results of this medication?
- A. Urine positive for glucose and negative for protein
- B. Urine specific gravity of 1.020 and negative for red blood cells
- C. White blood cell count 18,000 mm^3 (18 × 10^9/L) and platelets 355,000 mm^3 (355 × 10^9/L)
- D. Blood urea nitrogen (BUN) 22 mg/dL (7.92 mmol/L) and creatinine levels of 2.1 mg/dL (185 mcmol/L)
Correct Answer: C
Rationale: IVIG is usually effective to rapidly increase the platelet count. It is thought to act by interfering with the attachment of antibody-coded platelets to receptors on the macrophage cells of the reticuloendothelial system. Corticosteroids may be prescribed to enhance vascular stability and decrease the production of antiplatelet antibodies. Based on this information, the remaining options are unrelated to the administration of this medication.
The home care nurse is preparing to visit a client diagnosed with Ménière's disease. The nurse reviews the primary health care provider prescriptions and expects to educate the client on which dietary measure?
- A. A low-fiber diet with decreased fluids
- B. A low-sodium diet and fluid restriction
- C. A low-fat diet with a restriction of citrus fruits
- D. A low-carbohydrate diet and the elimination of red meats
Correct Answer: B
Rationale: Dietary changes such as salt and fluid restrictions that reduce the amount of endolymphatic fluid are sometimes prescribed for clients with Ménière's disease. None of the remaining options are prescribed for this disorder.
The nurse is caring for a client who has been diagnosed with tuberculosis. The client is receiving 600 mg of oral rifampin daily. Which laboratory finding would indicate to the nurse that the client is experiencing an adverse effect?
- A. A sedimentation rate of 15 mm/hour
- B. A white blood cell count of 6000 mm^3 (6 × 10^9/L)
- C. A total bilirubin level of 0.3 mg/dL (5.1 mcmol/L)
- D. Alanine aminotransferase (ALT) of 80 U/L (80 U/L)
Correct Answer: D
Rationale: Adverse or toxic effects of rifampin include hepatotoxicity, hepatitis, jaundice, blood dyscrasias, Stevens-Johnson syndrome, and antibiotic-related colitis. The nurse monitors for increased liver function, bilirubin, blood urea nitrogen, and uric acid levels because elevations indicate an adverse effect. The normal ALT level is 4 to 36 U/L (4 to 36 U/L). The normal total bilirubin level is 0.3 to 1.0 mg/dL (5.1 to 17 mcmol/L). The normal sedimentation rate is 0 to 30 mm/hour. A normal white blood cell count is 5000 to 10,000 mm^3 (5 to 10 × 10^9/L).
What is the nurse's priority for the postprocedure care of a client who has just returned to the unit after a scheduled intravenous pyelogram (IVP)?
- A. Maintaining the client on bed rest
- B. Ambulating the client in the hallway
- C. Encouraging the increased intake of oral fluids
- D. Encouraging the client to try to void frequently
Correct Answer: C
Rationale: After IVP, the client should take in increased fluids to aid in the clearance of the dye used for the procedure. The client is usually allowed activity as tolerated, without any specific activity guidelines. It is unnecessary to void frequently after the procedure.