Nokea
The nurse is assessing a client with suspected meningitis. Which finding is most concerning?
- A. Fever of 101°F.
- B. Neck stiffness.
- C. Mild headache.
- D. Fatigue.
Correct Answer: B
Rationale: Neck stiffness is a hallmark sign of meningitis, indicating meningeal irritation and requiring urgent evaluation.
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A client with a history of chronic kidney disease is admitted with edema. The nurse should monitor the client for which of the following electrolyte imbalances? Select all that apply.
- A. Hyperkalemia.
- B. Hyponatremia.
- C. Hypocalcemia.
- D. Hypermagnesemia.
- E. Hypophosphatemia.
Correct Answer: A, B, C, D
Rationale: Chronic kidney disease can cause hyperkalemia, hyponatremia, hypocalcemia, and hypermagnesemia due to impaired excretion and filtration.
Which couple is at greatest risk for domestic violence?
- A. A couple which consists of a husband and wife both of whom are affected with Alzheimer's disease
- B. A poverty stricken couple without any healthcare resources in the community
- C. A pregnant woman and a husband who was physically abused as a young child
- D. A wealthy couple with feelings that they are immune from punishment and above the law
Correct Answer: C
Rationale: A history of childhood physical abuse is a significant risk factor for perpetrating domestic violence, as it may lead to learned behaviors or unresolved trauma. Pregnancy can also increase stress and vulnerability, further elevating the risk.
A client is admitted with a diagnosis of acute pancreatitis. The nurse should expect the client to report which of the following symptoms?
- A. Pain radiating to the right shoulder.
- B. Epigastric pain radiating to the back.
- C. Right lower quadrant pain.
- D. Diffuse lower abdominal pain.
Correct Answer: B
Rationale: Acute pancreatitis typically causes epigastric pain that radiates to the back due to pancreatic inflammation.
The nurse understands that the client is responding favorably to a prescription for colchicine when there is a decrease in which sign/symptom?
- A. Headaches
- B. Joint inflammation
- C. Blood glucose level
- D. Serum triglyceride level
Correct Answer: B
Rationale: Colchicine is classified as an antigout agent. It interferes with the ability of the white blood cells to initiate and maintain an inflammatory response to monosodium urate crystals. The client should report a decrease in pain and inflammation in affected joints, as well as a decrease in the number of gout attacks. The other options are not related to the use of this medication.
A client has a positive sputum culture for Mycobacterium tuberculosis and is prescribed streptomycin as part of the treatment. The nurse determines that the client is experiencing a toxic effect of the medication when which test result is abnormal?
- A. Vision testing
- B. Hepatic enzymes
- C. Hemoglobin and hematocrit
- D. Blood urea nitrogen (BUN) and creatinine
Correct Answer: D
Rationale: BUN and creatinine are measured during therapy with streptomycin because the medication is nephrotoxic. Vision testing is done during treatment with ethambutol. The client taking isoniazid for tuberculosis is at risk for hepatotoxicity. Hemoglobin and hematocrit are not specifically related to tuberculosis.