Nokea
The nurse is caring for a client with a suspected stroke. Which assessment finding is most indicative of a stroke?
- A. Chest pain
- B. Sudden confusion and difficulty speaking
- C. Gradual onset of weakness in the legs
- D. Nausea and vomiting
Correct Answer: B
Rationale: The correct answer is B: Sudden confusion and difficulty speaking. These are classic signs of a stroke, indicating a neurological deficit that requires urgent medical attention. Choices A, C, and D are less indicative of a stroke. Chest pain is more commonly associated with cardiac issues, gradual onset of weakness in the legs could be related to other conditions like peripheral neuropathy, and nausea/vomiting may suggest gastrointestinal problems rather than a stroke.
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A client with hyperthyroidism is prescribed methimazole. Which adverse effect should the nurse monitor for?
- A. Agranulocytosis
- B. Hypoglycemia
- C. Bradycardia
- D. Hypercalcemia
Correct Answer: A
Rationale: The correct answer is Agranulocytosis. Methimazole, used to treat hyperthyroidism, can lead to agranulocytosis, a severe decrease in white blood cells. This condition increases the risk of infections and requires immediate medical attention. Hypoglycemia (choice B) is not a common adverse effect of methimazole. Bradycardia (choice C) is unlikely as methimazole tends to have minimal effects on heart rate. Hypercalcemia (choice D) is not associated with methimazole use.
A client with rheumatoid arthritis has elevated serum rheumatoid factor. Which interpretation of this finding should the nurse make?
- A. Evidence of spread of the disease to the kidney.
- B. Confirmation of the autoimmune disease process.
- C. Representative of a decline in the client's condition.
- D. Indication of the onset of joint degeneration.
Correct Answer: B
Rationale: The correct interpretation of elevated serum rheumatoid factor in a client with rheumatoid arthritis is confirmation of the autoimmune disease process. Rheumatoid factor is a marker for autoimmune activity, thus confirming the diagnosis of rheumatoid arthritis. Choice A is incorrect as elevated rheumatoid factor does not specifically indicate spread of the disease to the kidney. Choice C is incorrect as elevated rheumatoid factor does not always represent a decline in the client's condition. Choice D is incorrect as elevated rheumatoid factor is not an indication of the onset of joint degeneration, but rather points towards autoimmune activity.
A healthcare worker with no known exposure to tuberculosis has received a Mantoux tuberculosis skin test. The nurse's assessment of the test after 62 hours indicates 5mm of erythema without induration. Which is the best initial nursing action?
- A. Review the healthcare worker's history for possible exposure to TB.
- B. Instruct the healthcare worker to return for a repeat test in 1 week.
- C. Refer the healthcare worker to a healthcare provider for isoniazid (INH) therapy.
- D. Document negative results in the healthcare worker's medical record.
Correct Answer: D
Rationale: A Mantoux tuberculosis skin test without induration is considered negative. In this case, with 5mm of erythema and no induration, the result is negative, indicating no current infection. The best initial nursing action is to document these negative results in the healthcare worker's medical record. Reviewing the history for possible exposure to TB is unnecessary as the test result is negative. Instructing the healthcare worker to return for a repeat test or referring for INH therapy is not warranted when the test is negative.
The nurse provides dietary instructions about iron-rich foods to a client with iron deficiency anemia. Which food selection made by the client indicates a need for additional instructions?
- A. Liver.
- B. Oranges.
- C. Leafy green vegetables.
- D. Kidney beans.
Correct Answer: B
Rationale: The correct answer is B: Oranges. Oranges are not a rich source of iron. Iron-rich foods include liver, leafy green vegetables, and kidney beans. Oranges are a good source of vitamin C but are not high in iron. Therefore, if the client selects oranges as an iron-rich food, it indicates a need for additional instructions on choosing foods high in iron.
Twelve hours following a unilateral total knee replacement, a client reports being unable to sleep because of severe incisional pain. What is the best initial nursing action?
- A. Administer a prescribed sedative.
- B. Reposition the client for comfort.
- C. Apply ice packs to the surgical site.
- D. Instruct the client in the use of the prescribed patient-controlled analgesia (PCA) pump.
Correct Answer: D
Rationale: Instructing the client in the use of the PCA pump is the best initial nursing action for managing severe incisional pain after knee replacement surgery. The PCA pump allows the client to self-administer pain medication effectively, promoting better pain management. Administering a sedative may mask the pain temporarily but doesn't address the root cause. Repositioning the client for comfort or applying ice packs may provide some relief but doesn't address the need for effective pain control as the PCA pump does.