Correct answer-C. Rationales: Option C strongly indicates a diagnosis of diphtheria, especially in the client who has an incomplete or questionable immunization status. Option A is associated with a diagnosis of group A streptococcal infections. Option B is commonly found in the client diagnosed with infectious mononucleosis. Option D is more likely with thrush or streptococcal infection.

Nursing process step: Assessment

Correct answer-D. Rationales: Blood is the primary mode of transmission for hepatitis B and C. The primary mode of transmission for hepatitis A is through fecal contamination of food or water. Hepatitis A is also commonly transmitted through sexual contact with people previously diagnosed with hepatitis A.

Nursing process step: Assessment

Correct answer-C. Rationales: The priority in treating a medical emergency is establishing or maintaining an airway and supplementing respiratory effort. The other options are also appropriate interventions for a client having an allergic or anaphylactic reaction. These interventions should follow airway and breathing interventions.

Nursing process step: Intervention

Correct answer-B. Rationales: A single dose of the vaccine HBV alone doesn’t give an employee active immunity. The employee should obtain a series of three HBV vaccines, with the second and third doses being given 1 and 6 months after the first dose. Standard precautions and hand washing should be practiced during the treatment of all clients. Because transmission of hepatitis A is primarily through the fecal route, enteric precautions should be initiated. Recapping needles greatly increases the employee’s risk of getting unintentional puncture wounds.

Nursing process step: Intervention

Correct answer-B. Rationales: Trismus isn’t a symptom of AIDS. Trismus, present in a client with tetany, is marked by painful spasms of the masticatory muscles. The other options are common developments of AIDS-related diseases. A sore throat suggests oral candidiasis. Kaposi’s sarcoma, the most common neoplasm found in a client with AIDS, appears as blue to violet lesions. Dementia occurs from cortical atrophy.

Nursing process step: Assessment

Correct answer-B. Rationales: The toxic effects of zidovudine result in reduced WBC count, bone marrow suppression, anemia, and low platelet count. The normal platelet range is 100,000 to 500,000/µL. Hematocrit, an indicator of anemia, is normal in the range of 36% to 50%. Potassium levels, normally 3.5 to 5.5 mEq/L, are unaffected by zidovudine.

Nursing process step: Evaluation

Correct answer-B. Rationales: The glucose level in a client diagnosed with bacterial meningitis is decreased. It may be normal in viral meningitis. An elevated protein level is seen in most cases of meningitis. Protein levels are higher in bacterial meningitis than in viral meningitis. Generally, cerebrospinal fluid (CSF) is purulent or turbid. Trauma during a lumbar puncture may cause the sample to appear bloody. Polymorphonuclear leukocytes are the predominant cells identified in a positive CSF sample from a client with bacterial meningitis; in viral meningitis, lymphocytes predominate.

Nursing process step: Analysis

Correct answer-C. Rationales: In Kernig’s sign, the client is in the supine position with knees flexed; a leg is flexed then at the hip so that the thigh is brought to a position perpendicular to the trunk. An attempt is then made to extend the knee. If meningeal irritation is present, the knee can’t be extended and attempts to extend the knee result in pain. Other common symptoms include stiff neck, headache, and fever. Cullen’s sign is the bluish discoloration of the periumbilical skin due to intraperitoneal hemorrhage. Koplik’s spots are reddened areas with grayish blue centers that are found on the buccal mucosa of a client with measles. Homans’ sign is used to evaluate the presence of deep vein thrombosis.

Nursing process step: Assessment

Correct answer-B. Rationales: Furosemide acts by blocking the reabsorption of sodium chloride, which causes a significant diuresis of isotonic urine. Loop diuretics also cause the renal vasculature to vasodilate, which increases their effect. Mannitol is an osmotic diuretic, which, when present, exerts an osmotic effect, causing water diuresis. Hydrochlorothiazide inhibits the reabsorption of sodium in the loop of Henle. One of the potassium-sparing diuretics, spironolactone, promotes potassium reabsorption and sodium secretion, which produces a mild diuretic effect.

Nursing process step: Intervention

Correct answer-B. Rationales: Excellent sources of potassium are cheese, beans, potatoes, broccoli, milk, and beef. Honey has a moderate amount of iron but has insignificant amounts of potassium.

Nursing process step: Evaluation

Correct answer-C. Rationales: Isoniazid is contraindicated in a client who takes phenytoin. Isoniazid can decrease the excretion of phenytoin or may enhance its effects. To avoid phenytoin intoxication, adjustments to the anticonvulsant should be initiated. Indications or contraindications for a client in the other options haven’t been documented.

Nursing process step: Evaluation

Correct answer-C. Rationales: Injection of the tuberculin test should result in a wheal about 6 to 10 mm in diameter. If no wheal appears, the injection was probably too deep. Another injection should be repeated at least 5 mm away from the initial site. PPD administration should be through a short (1/2”) 26G or 27G needle. The amount of PPD injection doesn’t vary from 5 tuberculin units, regardless of the age or weight of the client. Reading the tuberculin skin test at the end of 24 hours results in an inaccurate diagnosis. The tuberculin skin tests are tests of delayed hypersensitivity and should be read in 48 to 72 hours.

Nursing process step: Intervention

Correct answer-B. Rationales: The client with tuberculosis should be informed that his sputum smears will remain positive for 3 to 5 months. The client should also be informed that he will no longer be infectious after 2 to 4 weeks of chemotherapy.

Nursing process step: Intervention

Correct answer-C. Rationales: Pheochromocytoma is a neoplasm associated with hyperfunction of the adrenal medulla. Although all age-groups can be affected, the disease primarily occurs in people between ages 30 and 60. It seldom occurs in clients over age 65. Common symptoms include sustained hypertension, vision disturbances, headaches, hyperglycemia, and excessive perspiration.

Nursing process step: Analysis

Correct answer-D. Rationales: The symptoms described are common manifestations of Cushing’s syndrome, a disorder of increased levels of glucocorticoids and corticotropin. Addison’s disease presents with hyperpigmentation, changes in sexual characteristics, and dehydration from sodium and fluid volume deficit. SIADH results in emotional and behavioral changes, hostility, anorexia, nausea, and weight gain. Graves’ disease, a result of hyperthyroidism, is evidenced by exophthalmos (protrusion of both eyeballs), fluid accumulation, tremors, and goiters.

Nursing process step: Assessment

Correct answer-C. Rationales: Regular insulin should be administered I.V. or S.C. and followed by an insulin drip to increase glucose use and decrease lipolysis. Hourly glucose levels should be obtained to monitor client response to interventions. The rate of insulin administration should be slowed as glucose levels near 200 to 300 mg/dl. Infusing additional dextrose products during diabetic ketoacidosis will worsen the client’s condition. I.V. replacement should initially be an infusion of isotonic saline to rehydrate the client, who is usually volume depleted. After hypovolemia and hyperglycemia have been addressed, the solution should be changed to D₅W and half-normal saline. Although NaHCO₃ is indicated for the correction of acidosis, it shouldn’t be initiated until decreased pH is confirmed by arterial blood gas analysis. If the client’s pH is less than 7.0, NaHCO₃ should be administered according to the physician’s orders until NaHCO₃ levels are adjusted. Potassium replacement isn’t always indicated in the treatment of diabetic ketoacidosis. Initially, potassium measurements can range from low to high. When levels are abnormal, cardiac monitoring should detect hypokalemia or hyperkalemia. Potassium replacement shouldn’t be initiated until urine output is established. If the client is suffering from acute renal failure, potassium replacement could produce toxic levels.

Nursing process step: Intervention