Nokea
The school nurse is assessing an elementary student with hemophilia who fell during recess. Which symptoms indicate hemarthrosis?
- A. Pain, coolness, and blue discoloration in the affected joint
- B. Tingling and pain without loss of movement in the affected joint
- C. Warmth, redness, and decreased movement in the affected joint
- D. Stiffness, aching, and decreased movement in the affected joint
Correct Answer: D
Rationale: Hemarthrosis in hemophilia involves bleeding into joints, causing stiffness, aching, and decreased movement due to joint swelling and pain.
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The nurse is teaching a client with a history of osteoporosis about fall prevention. The nurse should tell the client to:
- A. Remove clutter from walkways
- B. Use high-heeled shoes
- C. Avoid handrails
- D. Keep rooms dimly lit
Correct Answer: A
Rationale: Removing clutter prevents falls in osteoporosis, reducing fracture risk.
The nurse is teaching a client with ulcerative colitis who has been prescribed sulfasalazine (Azulfidine). What clinical manifestations will the nurse tell the client to be particularly alert for when taking this drug?
- A. Flu-like symptoms
- B. Purplish rash
- C. Skin blisters
- D. Anorexia
- E. Nausea
Correct Answer: A, B, C, E
Rationale: Sulfasalazine side effects include flu-like symptoms (A), purplish rash (B), skin blisters (C), and nausea (E). Anorexia (D) is less common.
The client is diagnosed with a urinary tract infection. Which instruction should the nurse include in the discharge teaching?
- A. Limit fluid intake to reduce bladder irritation.'
- B. Take all prescribed antibiotics as directed.'
- C. Avoid sexual activity permanently.'
- D. Use heating pads to relieve discomfort.'
Correct Answer: B
Rationale: Completing the full course of antibiotics is essential to eradicate the infection and prevent resistance in a urinary tract infection. Fluid intake should increase, sexual activity can resume after treatment, and heating pads may not be advised.
The physician has scheduled a Whipple procedure for a client with pancreatic cancer. The nurse recognizes that the client's cancer is located in:
- A. The tail of the pancreas
- B. The head of the pancreas
- C. The body of the pancreas
- D. The entire pancreas
Correct Answer: B
Rationale: The Whipple procedure (pancreaticoduodenectomy) is performed for cancer in the head of the pancreas, removing the head, duodenum, and other structures. Tail or body cancers require different surgeries.
The nurse is caring for a client with a spinal cord injury at C5. Which complication is the client at greatest risk for?
- A. Respiratory depression
- B. Autonomic dysreflexia
- C. Pressure ulcers
- D. Deep vein thrombosis
Correct Answer: A
Rationale: A C5 spinal cord injury impairs diaphragm function (innervated by C3–C5), placing the client at greatest risk for respiratory depression due to weak respiratory muscles. The other complications are risks but less immediate.