Nokea
Which of the following findings would be expected in the infant with biliary atresia?
- A. Rapid weight gain and hepatomegaly
- B. Dark stools and poor weight gain
- C. Abdominal distention and poor weight gain
- D. Abdominal distention and rapid weight gain
Correct Answer: C
Rationale: Biliary atresia causes bile flow obstruction, leading to abdominal distention (from hepatomegaly) and poor weight gain due to malabsorption. Stools are pale, not dark, and weight gain is not rapid.
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A client has a tentative diagnosis of myasthenia gravis. The nurse recognizes that myasthenia gravis involves:
- A. Loss of the myelin sheath in portions of the brain and spinal cord
- B. An interruption in the transmission of impulses from nerve endings to muscles
- C. Progressive weakness and loss of sensation that begins in the lower extremities
- D. Loss of coordination and stiff 'cogwheel' rigidity
Correct Answer: B
Rationale: Myasthenia gravis is caused by autoantibodies blocking acetylcholine receptors, interrupting nerve impulse transmission to muscles, leading to weakness.
The nurse is caring for an older client hospitalized with dehydration. Which site should be used to check for skin turgor?
- A. Hand
- B. Arm
- C. Abdomen
- D. Forehead
Correct Answer: C
Rationale: In older adults the abdomen is the most reliable site for assessing skin turgor due to age-related changes in skin elasticity on the hands and arms. The forehead is not a standard site for this assessment.
A client is admitted with symptoms of pseudomembranous colitis. Which finding is associated with Clostridium difficile?
- A. Diarrhea containing blood and mucus
- B. Cough, fever, and shortness of breath
- C. Anorexia, weight loss, and fever
- D. Development of ulcers on the lower extremities
Correct Answer: A
Rationale: Clostridium difficile causes pseudomembranous colitis, characterized by diarrhea with blood and mucus due to toxin-mediated inflammation of the colon.
A client is diagnosed with Mycobacterium tuberculosis. He is placed in respiratory isolation, intubated, and receives mechanical ventilation. When performing suctioning, the nurse should:
- A. Suction for a maximum of 20 seconds
- B. Hyperoxygenate before and after suctioning
- C. Suction for a maximum of 30 seconds
- D. Maintain clean technique during suctioning
Correct Answer: B
Rationale: Supplemental O2 should be administered before and after suctioning to reduce hypoxia.
The nurse is caring for a client with a diagnosis of rheumatoid arthritis who is receiving methotrexate. Which laboratory value would be most concerning?
- A. WBC 4,000/mm3
- B. Platelet count 150,000/mm3
- C. Hemoglobin 13 g/dL
- D. Serum creatinine 1.2 mg/dL
Correct Answer: A
Rationale: Methotrexate can cause bone marrow suppression. A WBC of 4,000/mm3 (A) indicates leukopenia, increasing infection risk, and is most concerning. Platelets (B), hemoglobin (C), and creatinine (D) are within normal limits.