Nokea
Which statement is true regarding the infant's susceptibility to pertussis?
- A. If the mother had pertussis, the infant will have passive immunity.
- B. Most infants and children are highly susceptible from birth.
- C. The newborn will be immune to pertussis for the first few months of life.
- D. Infants under 1 year of age seldom get pertussis.
Correct Answer: B
Rationale: Infants are highly susceptible to pertussis from birth, as maternal immunity is minimal, and severe cases are common in this age group.
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A 51-year-old client received a kidney transplant. Which of the following signs and symptoms indicates possible rejection of the kidney? Select all that apply.
- A. increased urine output
- B. increase in blood pressure
- C. weight gain
- D. pain in lower back
- E. decreased creatinine
Correct Answer: B,C,D
Rationale: Kidney rejection causes hypertension (B), fluid retention (weight gain, C), and graft pain (D). Decreased urine output (not increased) and elevated creatinine (not decreased) are typical.
A client admitted with hepatic encephalopathy continues to attempt ambulation without assistance despite repeated instruction. Which intervention should the nurse take to promote safety?
- A. administer Xanax 6 mg PO
- B. apply a vest restraint device
- C. request a family member stay with the client around the clock
- D. move the client closer to the nurses' station
Correct Answer: D
Rationale: Moving the client closer to the nurses’ station allows frequent monitoring, promoting safety without restraints or sedation, which are less appropriate.
The nurse is caring for a client with dementia who tends to wander. Which of the following actions can help with this behavior? Select all that apply.
- A. providing frequent toileting or incontinence care as needed
- B. assessing client for pain and treat with appropriate medications
- C. reorienting the client and use validation therapy, as appropriate
- D. allowing the client to sit in a recliner at the nurses' station for close monitoring
- E. using chemical or physical restraints to prevent the client from exiting the bed
Correct Answer: A, B, C, D
Rationale: Frequent toileting, pain management, reorientation, and close monitoring address wandering causes and promote safety. Restraints are a last resort and not ideal for wandering.
A 65-year-old client is admitted after a stroke. The nurse is concerned about skin breakdown and decubitus ulcer development. Which nursing intervention would best improve tissue perfusion to prevent skin problems?
- A. Assessing the skin daily
- B. Massaging any erythematous areas on the skin
- C. Changing incontinence pads as soon as they become soiled
- D. Performing range-of-motion exercises and turning and repositioning the client
Correct Answer: D
Rationale: Performing range-of-motion exercises and turning/repositioning the client promotes blood circulation, which enhances tissue perfusion and prevents pressure ulcers. Assessing the skin detects problems but doesn't improve perfusion, massaging erythematous areas can worsen tissue damage, and changing pads addresses hygiene but not perfusion directly.
A client with paranoid schizophrenia has an order for Thorazine (chlorpromazine) 400 mg orally twice daily. Which of the following symptoms should be reported to the physician immediately?
- A. Fever, sore throat, weakness
- B. Dry mouth, constipation, blurred vision
- C. Lethargy, slurred speech, thirst
- D. Fatigue, drowsiness, photosensitivity
Correct Answer: A
Rationale: Fever, sore throat, and weakness may indicate agranulocytosis, a serious side effect of chlorpromazine requiring immediate reporting.