Nokea
The nurse is talking to a client and his family about hepatitis. Which of the following statements by a family member indicate understanding of the nurse's teaching? Select all that apply.
- A. Hepatitis D only occurs with hepatitis B.
- B. Hepatitis A can occur at any time of the year.
- C. Hepatitis D is transmitted through contaminated drinking water.
- D. Hepatitis A can be spread by uncooked shellfish and contaminated water or milk.
- E. Hepatitis B is spread by contact with blood or body fluids, sexual contact, or sharing dirty needles.
Correct Answer: A, B, D, E
Rationale: Hepatitis D requires hepatitis B, hepatitis A is year-round and spread via contaminated food/water, and hepatitis B is transmitted through blood/body fluids. Hepatitis D is not waterborne.
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A neurological consult has been ordered for a pediatric client with suspected absence seizures. The client with absence seizures can be expected to have:
- A. Short, abrupt muscle contractions
- B. Quick, severe bilateral jerking movements
- C. Abrupt loss of muscle tone
- D. Brief lapse in consciousness
Correct Answer: D
Rationale: Absence seizures cause brief lapses in consciousness, often appearing as staring spells, without motor symptoms.
A client elects to have epidural anesthesia to relieve the discomfort of labor. Following the initiation of epidural anesthesia, the nurse should give priority to:
- A. Checking for cervical dilation
- B. Placing the client in a supine position
- C. Checking the client's blood pressure
- D. Obtaining a fetal heart rate
Correct Answer: C
Rationale: Epidural anesthesia can cause hypotension, making blood pressure monitoring a priority.
A 5-month-old infant is admitted to the ER with a temperature of 103.6°F and irritability. The mother states that the child has been listless for the past several hours and that he had a seizure on the way to the hospital. A lumbar puncture confirms a diagnosis of bacterial meningitis. The nurse should assess the infant for:
- A. Periorbital edema
- B. Tenseness of the anterior fontanel
- C. Positive Babinski reflex
- D. Negative scarf sign
Correct Answer: B
Rationale: Tenseness of the anterior fontanel indicates increased intracranial pressure, a critical finding in bacterial meningitis in infants.
A client is admitted with possible appendicitis. Which finding by the nurse would be expected in assessment of this client?
- A. a positive psoas sign
- B. a positive Murphy's sign
- C. a positive Homan's sign
- D. a positive Chadwick's sign
Correct Answer: A
Rationale: A positive psoas sign (pain with leg extension) is associated with appendicitis. Murphy’s sign is for gallbladder, Homan’s for DVT, and Chadwick’s for pregnancy.
The nurse is developing a plan of care for a client with an ileostomy. The priority nursing diagnosis is:
- A. Fluid volume deficit
- B. Alteration in body image
- C. Impaired oxygen exchange
- D. Alteration in elimination
Correct Answer: A
Rationale: Fluid volume deficit is the priority due to the risk of dehydration from high ileostomy output, which can lead to electrolyte imbalances and other complications.