Nokea
Which finding is associated with Tay Sachs disease?
- A. Pallor of the conjunctiva
- B. Cherry-red spots on the macula
- C. Blue-tinged sclera
- D. White flecks in the iris
Correct Answer: B
Rationale: Cherry-red spots on the macula are a classic finding in Tay-Sachs disease due to lipid accumulation in retinal ganglion cells.
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The nurse is caring for a child in a plaster-of-Paris hip spica cast. To facilitate drying, the nurse should:
- A. Use a small hand-held hair dryer set on medium heat
- B. Place a small heater near the child's bed
- C. Turn the child at least every 2 hours
- D. Allow one side to dry before changing positions
Correct Answer: C
Rationale: Turning the child every 2 hours ensures even drying of the cast and prevents pressure sores, promoting comfort and healing.
The physician has ordered a minimal-bacteria diet for a client with neutropenia. The client should be taught to avoid eating:
- A. Fruits
- B. Salt
- C. Pepper
- D. Ketchup
Correct Answer: A
Rationale: Raw fruits may harbor bacteria, posing an infection risk for a neutropenic client on a minimal-bacteria diet.
A client is admitted with disseminated herpes zoster. According to the Centers for Disease Control Guidelines for Infection Control:
- A. Airborne precautions will be needed.
- B. No special precautions will be needed.
- C. Contact precautions will be needed.
- D. Droplet precautions will be needed.
Correct Answer: A
Rationale: Disseminated herpes zoster requires airborne precautions due to the risk of varicella-zoster virus transmission through respiratory droplets and contact.
Which laboratory test would be the least effective in making the diagnosis of a myocardial infarction?
- A. AST
- B. Troponin
- C. CK-MB
- D. Myoglobin
Correct Answer: A
Rationale: AST is less specific for myocardial infarction than troponin, CK-MB, or myoglobin.
The nurse on oncology is caring for a client with a white blood count of 600. During evening visitation, a visitor brings a potted plant. What action should the nurse take?
- A. Allow the client to keep the plant
- B. Place the plant by the window
- C. Water the plant for the client
- D. Tell the family members to take the plant home
Correct Answer: D
Rationale: A low WBC (neutropenia) increases infection risk, so the plant, which may harbor bacteria or fungi, should be removed.