Nokea
The nurse is assessing a client with suspected appendicitis. Which of the following findings supports this diagnosis?
- A. Pain at McBurney's point.
- B. Left lower quadrant pain.
- C. Decreased bowel sounds.
- D. Absence of fever.
Correct Answer: A
Rationale: Pain at McBurney's point (right lower quadrant) is a hallmark sign of appendicitis due to localized peritoneal irritation.
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The nurse is caring for a client with a ventricular shunt for hydrocephalus. Which finding requires immediate reporting?
- A. Clear drainage from the incision
- B. Mild headache
- C. Temperature of 98.6°F (37°C)
- D. Pupils equal and reactive
Correct Answer: A
Rationale: Clear drainage from a shunt incision may indicate cerebrospinal fluid leakage, a serious complication requiring immediate reporting.
The nurse is caring for a client with a history of atrial fibrillation who is prescribed dronedarone (Multaq). The nurse should monitor the client for which of the following side effects?
- A. Hypertension.
- B. Bradycardia.
- C. Liver toxicity.
- D. Weight gain.
Correct Answer: C
Rationale: Dronedarone can cause liver toxicity, requiring regular monitoring of liver function tests.
A client with a diagnosis of chronic heart failure is prescribed digoxin (Lanoxin). The nurse should monitor the client for which of the following signs of toxicity?
- A. Tachycardia.
- B. Yellow vision.
- C. Weight gain.
- D. Dry cough.
Correct Answer: B
Rationale: Yellow vision is a classic sign of digoxin toxicity, indicating the need for immediate evaluation.
The nurse is assessing a client who is suspected of being in the early symptomatic stages of human immunodeficiency virus (HIV) infection. Which of the following signs and symptoms of infection should the nurse detect during this stage?
- A. Whitish yellow patches in the mouth.
- B. Dyspnea.
- C. Mild diarrhea.
- D. Raised, hyperpigmented lesions on the legs.
Correct Answer: C
Rationale: Mild diarrhea is a common early symptom of HIV infection, unlike the other options, which appear in later stages.
A mother who is Mexican brings her 2-month-old son to the emergency department with a high fever and possible sepsis. A lumbar puncture is ordered, but the mother will not sign the consent until the father arrives to give permission. The nurse should:
- A. Report this to the social worker
- B. Call Child Protective Services
- C. Wait until the father arrives
- D. Inform the physician that the mother has refused to have the procedure
Correct Answer: C
Rationale: Respecting cultural norms, where the father may be the decision-maker, the nurse should wait for the father to arrive for consent, especially in a non-immediate life-threatening situation. Reporting to social services or claiming refusal is premature without further assessment.