Nokea
The nurse is obtaining a nursing history of a client suspected of having hepatitis C. The nurse should ask the client if he has:
- A. Drunk contaminated water.
- B. Traveled to India.
- C. Had a tattoo.
- D. Eaten shellfish.
Correct Answer: C
Rationale: Hepatitis C is commonly transmitted through blood exposure, such as via tattoos with unsterile equipment. The other options are more associated with hepatitis A.
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The nurse is assessing a client with a suspected diverticulitis. Which of the following findings is most indicative of this condition?
- A. Left lower quadrant pain.
- B. Right upper quadrant pain.
- C. Soft, nontender abdomen.
- D. Frequent loose stools.
Correct Answer: A
Rationale: Left lower quadrant pain is a hallmark sign of diverticulitis due to inflammation of diverticula in the sigmoid colon.
The nurse observes an 18-month-old who has been admitted with a respiratory tract infection (see figure). The nurse should first:
- A. Position the child supine
- B. Call the rapid response team
- C. Offer the child a carbonated drink
- D. Place the child in a croup tent
Correct Answer: B
Rationale: An 18-month-old with a respiratory tract infection may be in respiratory distress, requiring immediate action by calling the rapid response team. Positioning supine or offering a drink could worsen breathing, and a croup tent is specific to croup, not all infections.
A client with a history of migraines is prescribed sumatriptan (Imitrex). The nurse should instruct the client to take the medication:
- A. Daily to prevent migraines.
- B. At the onset of a migraine.
- C. With meals to enhance absorption.
- D. At bedtime to reduce side effects.
Correct Answer: B
Rationale: Sumatriptan is most effective when taken at the onset of a migraine to abort the headache.
Which of the following is a priority nursing diagnosis for the client presenting with pelvic inflammatory disease?
- A. Imbalanced nutrition: Less than body requirements.
- B. Bathing/hygiene self-care deficit.
- C. Acute pain.
- D. Impaired skin integrity.
Correct Answer: C
Rationale: Acute pain is the priority diagnosis for pelvic inflammatory disease, as it is a hallmark symptom requiring immediate management.
A client with a history of heart failure is prescribed spironolactone (Aldactone). The nurse should instruct the client to:
- A. Avoid potassium-rich foods.
- B. Take the medication at bedtime.
- C. Monitor blood pressure regularly.
- D. Stop the medication if dizziness occurs.
Correct Answer: A, C
Rationale: Spironolactone can cause hyperkalemia, requiring avoidance of potassium-rich foods, and blood pressure monitoring for hypotension.