A 15-year-old primigravida is admitted with a tentative diagnosis of HELLP syndrome. Which laboratory finding is associated with HELLP syndrome?
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Solution
Elevated hepatic enzymes
The criteria for HELLP is hemolysis, elevated liver enzymes, and low platelet count.
Option A: An elevated blood glucose level is not associated with HELLP.
Option B: Platelets are decreased, not elevated, in HELLP syndrome.
Option C: The creatinine levels are elevated in renal disease and are not associated with HELLP syndrome.
A client visiting a family planning clinic is suspected of having an STI. The best diagnostic test for treponema pallidum is:
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Solution
Fluorescent treponemal antibody (FTA)
Fluorescent treponemal antibody (FTA) is the test for treponema pallidum.
Options A and B: VDRL and RPR are screening tests done for syphilis.
Option D: The Thayer-Martin culture is done for gonorrhea.
During the initial interview, the client reports that she has a lesion on the perineum. Further investigation reveals a small blister on the vulva that is painful to touch. The nurse is aware that the most likely source of the lesion is:
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Solution
Herpes
A lesion that is painful is most likely a herpetic lesion.
Option A: A chancre lesion associated with syphilis is not painful.
Option C: Gonorrhea does not present as a lesion, but is exhibited by a yellow discharge.
Option D: Condylomata lesions are painless warts, so answer D is incorrect.
A client with a diagnosis of HPV is at risk for which of the following?
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Solution
Cervical cancer
The client with HPV is at higher risk for cervical and vaginal cancer related to this STI. She is not at higher risk for the other cancers mentioned in answers A, C, and D, so those are incorrect.
A client is admitted to the labor and delivery unit in active labor. During examination, the nurse notes a papular lesion on the perineum. Which initial action is most appropriate?
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Solution
Report the finding to the doctor
Any lesion should be reported to the doctor. This can indicate a herpes lesion. Clients with open lesions related to herpes are delivered by Cesarean section because there is a possibility of transmission of the infection to the fetus with direct contact to lesions.
Option A: It is not enough to document the finding.
Option C: The physician must make the decision to perform a C-section.
Option D: It is not enough to continue primary car.
The doctor has prescribed Exelon (rivastigmine) for the client with Alzheimer’s disease. Which side effect is most often associated with this drug?
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Solution
Nausea
Nausea and gastrointestinal upset are very common in clients taking acetylcholinesterase inhibitors such as Exelon. Other side effects include liver toxicity, dizziness, unsteadiness, and clumsiness.
Options A, B, and C: The client might already be experiencing urinary incontinence or headaches, but they are not necessarily associated, and the client with Alzheimer’s disease is already confused.
The client with confusion says to the nurse, “I haven’t had anything to eat all day long. When are they going to bring breakfast?” The nurse saw the client in the day room eating breakfast with other clients 30 minutes before this conversation. Which response would be best for the nurse to make?
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Solution
“I’ll get you some juice and toast. Would you like something else?”
The client who is confused might forget that he ate earlier. Don’t argue with the client. Simply get him something to eat that will satisfy him until lunch.
Options A and D are incorrect because the nurse is dismissing the client.
Option B is validating the delusion.
The client with dementia is experiencing confusion late in the afternoon and before bedtime. The nurse is aware that the client is experiencing what is known as:
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Solution
Sundowning
Increased confusion at night is known as “sundowning” syndrome. This increased confusion occurs when the sun begins to set and continues during the night.
Option A: Fatigue is not necessarily present.
Option B: Increased confusion at night is not part of normal aging.
Option D: A delusion is a firm, fixed belief.
The client with Alzheimer’s disease is being assisted with activities of daily living when the nurse notes that the client uses her toothbrush to brush her hair. The nurse is aware that the client is exhibiting:
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Solution
Agnosia
Agnosia is the term used to describe the loss of the ability to recognize what objects are and what they are used for. For an instance, a person with agnosia might try to use a fork instead of a spoon, a shoe instead of a cup or a knife instead of a pencil etc. With regard to people, this might involve failing to recognize who people are, not due to memory loss but rather as a result of the brain not working out the identity of a person on the basis of the information supplied by the eyes.
Option B: Apraxia is the term used to describe the failure to carry out voluntary and purposeful movements notwithstanding the fact that muscular power, sensibility, and coordination are intact. In everyday terms, this might involve the inability to tie shoelaces, turn a tap on, fasten buttons or switch on a radio.
Options C and D: Aphasia is the term used to describe a difficulty or loss of the ability to speak or understand spoken, written or sign language as a result of damage to the corresponding nervous center. This can become apparent in a number of ways. It might involve exchanging a word which is linked by meaning (e.g. time instead of clock), using the wrong word but one which sounds alike (e.g. boat instead of coat) or using a totally different word with no apparent connection. When accompanied by echolalia (the involuntary repetition of words or phrases spoken by another person) and the constant repetition of a word or phrase, the result can be a form of speech which is difficult for others to understand or a kind of jargon. Anomia is a form of aphasia in which the patient is unable to recall the names of everyday objects.
The client with suspected meningitis is admitted to the unit. The doctor is performing an assessment to determine meningeal irritation and spinal nerve root inflammation. A positive Kernig’s sign is charted if the nurse notes:
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Solution
Pain on flexion of the hip and knee
Kernig’s sign is positive if pain occurs on flexion of the hip and knee.
Option B: The Brudzinski reflex is positive if pain occurs on flexion of the head and neck onto the chest.
Options C and D: These symptoms might be present but are not related to Kernig’s sign.