Nokea
The nurse is interviewing a client about his past medical history. Which preexisting condition may lead the nurse to suspect that a client has colorectal cancer?
- A. Duodenal ulcer
- B. Weight gain
- C. Hemorrhoids
- D. Polyps
Correct Answer: D
Rationale: The presence of polyps in the colon is a significant risk factor for developing colorectal cancer. Polyps are abnormal growths in the inner lining of the colon or rectum that can potentially become cancerous over time if left untreated. Therefore, if a client has a history of polyps, the nurse may suspect the possibility of colorectal cancer and should closely monitor the client for any signs or symptoms. While the other conditions listed may sometimes be associated with colorectal cancer, having a history of polyps is the most concerning in this context.
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As the nurse collects data on a patient, which of the following is a symptom that may be found that the patient with anaphylaxis may be experiencing?
- A. Dermatitis
- B. Sinusitis
- C. Delirium
- D. Wheezing
Correct Answer: D
Rationale: Wheezing is a common symptom of anaphylaxis, along with other signs such as difficulty breathing, chest tightness, coughing, and throat swelling. Wheezing is caused by the constriction of the airways due to the body's extreme immune response to the allergen, leading to difficulty in breathing and wheezing sounds during respiration. It is important for healthcare professionals to recognize wheezing as a symptom of anaphylaxis and respond promptly with appropriate interventions, such as administering epinephrine and providing respiratory support.
In fetal period, all are true EXCEPT
- A. 10 weeks - midgut returns to abdomen
- B. 12 weeks - external genitalia formed
- C. 24 weeks - surfactant production begun
- D. 26 weeks - face clearly recognizable
Correct Answer: D
Rationale: Face recognition typically occurs earlier than 26 weeks.
A 3-year-old child from a suburban community presents with vomiting, diarrhea, and blurred vision. Physical examination reveals an afebrile child with pinpoint pupils, salivation, and muscular fasciculations. The child's lawn was treated yesterday for insects. Which of the following tests will establish the correct diagnosis?
- A. Blood-lead level
- B. 24-hour urine mercury level
- C. Plasma cholinesterase level
- D. Urine malathion level
Correct Answer: C
Rationale: The symptoms suggest organophosphate poisoning, which can be confirmed by measuring plasma cholinesterase levels, as organophosphates inhibit this enzyme.
Nursing measures in hemodynamic monitoring include assessing for localized ischemia owing to inadequate arterial flow. The nurse should:
- A. Assess the involved extremity for color and temperature
- B. Check for capillary refill
- C. Evaluate pulse rate
- D. Do all of the above
Correct Answer: D
Rationale: When assessing for localized ischemia owing to inadequate arterial flow, it is important for the nurse to perform all of the mentioned actions:
The nurse is caring for an adolescent who had an external fixator placed after suffering a fracture of the wrist during a bicycle accident. Which statement by the adolescent should be expected about separation anxiety?
- A. "I wish my parents could spend the night with me while I am in the hospital."
- B. "I think I would like for my siblings to visit me but not my friends."
- C. "I hope my friends don't forget about visiting me."
- D. "I will be embarrassed if my friends come to the hospital to visit."
Correct Answer: A
Rationale: Separation anxiety is a common response in adolescents who have had to be separated from their family and friends due to hospitalization or medical treatment. In this situation, the adolescent expressing a desire for their parents to spend the night with them in the hospital is indicative of separation anxiety. They may feel comforted and secure by having their parents close by during this challenging time. The other statements do not directly reflect separation anxiety but rather focus on preferences for visitors and concerns about embarrassment.