Nokea
The nurse is caring for a client with acquired immunodeficiency syndrome. Which finding should be reported to the doctor immediately?
- A. Temperature of 100.2°F
- B. White patches on the tongue
- C. Weight loss of 10 pounds
- D. Respiratory rate of 26 breaths per minute
Correct Answer: D
Rationale: A respiratory rate of 26 breaths per minute suggests respiratory distress, a critical issue in AIDS due to possible opportunistic infections like Pneumocystis pneumonia, requiring immediate reporting.
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The nurse is caring for a client following a cerebral vascular accident. Which portion of the brain is responsible for changes in the client's vision?
- A. Temporal lobe
- B. Frontal lobe
- C. Occipital lobe
- D. Parietal lobe
Correct Answer: C
Rationale: The occipital lobe processes visual information. A cerebral vascular accident affecting this area can cause visual deficits such as hemianopia or visual agnosia. The temporal lobe manages auditory and memory functions, the frontal lobe controls behavior and motor skills, and the parietal lobe handles sensory integration.
A client is diagnosed with emphysema and cor pulmonale. Which findings are characteristic of cor pulmonale?
- A. Hypoxia, shortness of breath, and exertional fatigue
- B. Weight loss, increased RBC, and fever
- C. Rales, edema, and enlarged spleen
- D. Edema of the lower extremities and distended neck veins
Correct Answer: D
Rationale: Cor pulmonale, right heart failure from lung disease, causes lower extremity edema and distended neck veins due to increased venous pressure. Hypoxia and fatigue are general emphysema symptoms.
The client is prescribed methotrexate for rheumatoid arthritis. Which instruction should the nurse include?
- A. Take the medication with milk to prevent stomach upset.'
- B. Report any signs of infection immediately.'
- C. Avoid exposure to sunlight.'
- D. Take the medication only when joint pain is severe.'
Correct Answer: B
Rationale: Methotrexate causes immunosuppression, increasing infection risk, so reporting signs of infection is critical. Milk does not prevent GI upset, photosensitivity is not a primary concern, and methotrexate is taken regularly, not as needed.
A client delivered a stillborn male at term. An appropriate action of the nurse would be to:
- A. State, 'You have an angel in heaven.'
- B. Discourage the parents from seeing the baby.
- C. Provide an opportunity for the parents to see and hold the baby for an undetermined amount of time.
- D. Reassure the parents that they can have other children.
Correct Answer: C
Rationale: This is not a supportive statement. There are also no data to indicate the family's religious beliefs. Seeing their baby assists the parents in the grieving process. This gives them the opportunity to say 'good-bye.' Parents need time to get to know their baby. This is not a comforting statement when a baby has died. There are also no guarantees that the couple will be able to have another child.
A client with a head injury has an order for dexamethasone (Decadron) 10 mg IV; push every 6 hours. The dose is available Decadron 4 mg/mL. How much will the nurse administer?
- A. mL(s)
Correct Answer: 2.5 mL
Rationale: Dose: 10 mg ÷ 4 mg/mL = 2.5 mL.