Nokea
A client has been on antibiotics for 72 hours for cystitis.
Which report from the client requires priority attention by the nurse?
- A. Dysuria
- B. Body malaise
- C. Rashes all over the body and slight breathing problems.
- D. Poor appetite.
Correct Answer: C
Rationale: Rashes and breathing problems are signs of a delayed allergic reaction to antibiotics, requiring urgent attention.
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A male patient with thrombophlebitis is apprehensive about the possibility of a clot reaching his heart, causing sudden death.
The nurse's initial intervention should be to:
- A. Clarify his misconception.
- B. Explain preventive measures.
- C. Teach recognition of early symptoms.
- D. Encourage discussion of the patient's concern.
Correct Answer: A
Rationale: Clarifying that thrombophlebitis clots rarely reach the heart addresses the patient's fear directly.
A child who has recently been diagnosed with cystic fibrosis (CF) is being assessed by a pediatric clinic nurse. Which finding of this disease would the nurse not expect to see at this time?
- A. Positive sweat test
- B. Bulky greasy stools
- C. Moist, productive cough
- D. Meconium ileus
Correct Answer: C
Rationale: Moist, productive cough. Option C is a later sign. Noisy respirations and a dry non-productive cough are commonly the first of the respiratory signs to appear in a newly diagnosed client with CF. The other options are the earliest findings. CF is an inherited (genetic) condition affecting the cells that produce mucus, sweat, saliva and digestive juices. Normally, these secretions are thin and slippery, but in CF, a defective gene causes the secretions to become thick and sticky. Instead of acting as a lubricant, the secretions plug up tubes, ducts and passageways, especially in the pancreas and lungs. Respiratory failure is the most dangerous consequence of CF.
The nurse is preparing to perform a physical examination on an 8 month-old who is sitting contentedly on his mother's lap. Which of the following should the nurse do first?
- A. Elicit reflexes
- B. Measure height and weight
- C. Auscultate heart and lungs
- D. Examine the ears
Correct Answer: C
Rationale: Auscultate heart and lungs. Performing this during a quiet moment ensures clear sound detection.
The patient with hypothyroidism
The patient with hypothyroidism will most likely experience which of the following?
- A. Diarrhea and weight gain.
- B. Warm skin and brittle nails.
- C. Dry skin and weight gain.
- D. Constipation and tachycardia.
Correct Answer: C
Rationale: Hypothyroidism causes dry skin and weight gain due to slowed metabolism.
When a patient return from the recovery room following a subtotal thyroidectomy, the nurse should immediately
inspect the incision.
- A. instruct the patient not to speak.
- B. keep the patient supine for 24 hours.
- C. place a tracheostomy set at the bedside.
Correct Answer: D
Rationale: Thyroid surgery sometimes results in accidental removal of the parathyroid glands. A resultant hypocalcemia may lead to contraction of the glottis, causing airway obstruction; edema also causes obstruction. Having a tracheostomy set ready is critical.