A 2-month-old infant has just received her first Tetramune injection. The nurse should tell the mother that the immunization:
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Solution
Answer C is correct. The immunization protects the child against diphtheria, pertussis, tetanus, and H. influenza b. Answer A is incorrect because a second injection is given before 4 years of age. Answer B is not a true statement; therefore, it is incorrect. Answer D is incorrect because it is not a one-time injection, nor does it protect against measles, mumps, rubella, or varicella.
A client with hyperthyroidism is taking lithium carbonate to inhibit thyroid hormone release. Which complaint by the client should alert the nurse to a problem with the client’s medication?
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Solution
Answer B is correct. Increased thirst and increased urination are signs of lithium toxicity. Answers A and D do not relate to the medication; therefore, they are incorrect. Answer C is an expected side effect of the medication; therefore, it is incorrect.
Which of the following meal selections is appropriate for the client with celiac disease?
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Solution
Answer C is correct. Foods containing rice or millet are permitted on the diet of the client with celiac disease. Answers A, B, and D are not permitted because they contain flour made from wheat, which exacerbates the symptoms of celiac disease; therefore, they are incorrect.
The nurse is admitting a client with a suspected duodenal ulcer. The client will most likely report that his abdominal discomfort lessens when he:
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Solution
Answer C is correct. Pain associated with duodenal ulcers is lessened if the client eats a meal or snack. Answer A is incorrect because it makes the pain worse. Answer B refers to dumping syndrome; therefore, it is incorrect. Answer D refers to gastroesophageal reflux; therefore, it is incorrect.
The nurse is caring for an 8-year-old following a routine tonsillectomy. Which finding should be reported immediately?
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Solution
Answer D is correct. Respiratory stridor is a symptom of partial airway obstruction. Answers A, B, and C are expected with a tonsillectomy; therefore, they are incorrect.
A client admitted to the psychiatric unit claims to be the Son of God and insists that he will not be kept away from his followers. The most likely explanation for the client’s delusion is:
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Solution
Answer C is correct. Delusions of grandeur are associated with low self-esteem. Answer A is incorrect because conversion is expressed as sensory or motor deficits. Answers B and D can cause an increase in the client’s delusions but do not explain their purpose; therefore, they are incorrect.
Which statement describes the contagious stage of varicella?
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Solution
Answer D is correct. The contagious stage of varicella begins 24 hours before the onset of the rash and lasts until all the lesions are crusted. Answers A, B, and C are inaccurate regarding the time of contagion; therefore, they are incorrect.
A client is admitted with a diagnosis of hypothyroidism. An initial assessment of the client would reveal:
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Solution
Answer B is correct. Symptoms of hypothyroidism include weight gain, lethargy, slow speech, and decreased respirations. Answers A and D do not describe symptoms associated with myxedema; therefore, they are incorrect. Answer C describes symptoms associated with Graves’s disease; therefore, it is incorrect.
A child with croup is placed in a cool, high-humidity tent connected to room air. The primary purpose of the tent is to:
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Solution
Answer D is correct. The primary reason for placing a child with croup under a mist tent is to liquefy secretions and relieve laryngeal spasms. Answer A is incorrect because it does not prevent insensible water loss. Answer B is incorrect because the oxygen concentration is too high. Answer C is incorrect because the mist tent does not prevent dehydration or reduce fever.
A 9-year-old is admitted with suspected rheumatic fever. Which finding is suggestive of polymigratory arthritis?
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Solution
Answer D is correct. The child with polymigratory arthritis will exhibit swollen, painful joints. Answer B is incorrect because it describes subcutaneous nodules. Answer C is incorrect because it describes erythema marginatum. Answer A is incorrect because it describes Syndeham’s chorea.