A nurse is caring for a patient diagnosed with Hodgkin disease who has significant cervical lymph node enlargement.
Which symptom should the nurse address first?
Fatigue
Pain
Fever
Stridor
The Correct Answer is D
Choice A rationale
While fatigue is a common symptom of Hodgkin’s disease, it is not the most urgent symptom to address when there is significant cervical lymph node enlargement.
Choice B rationale
Pain can be a symptom of Hodgkin’s disease, but it is not the most urgent symptom to address in this case.
Choice C rationale
Fever can be a symptom of Hodgkin’s disease, but it is not the most urgent symptom to address in this case.
Choice D rationale
Stridor is a high-pitched, wheezing sound caused by disrupted airflow. Stridor may indicate a serious condition affecting the throat or larynx (voice box). With significant cervical lymph node enlargement, the lymph nodes may be pressing on the airway, causing stridor. This is a medical emergency and should be addressed first.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Taking two tablets every 15 minutes is not the recommended dosing for nitroglycerin. Overdosing can lead to hypotension and other side effects.
Choice B rationale
While the client should take the nitroglycerin sublingually, taking one tablet every 15 minutes up to 5 times is not the recommended dosing. This could lead to an overdose.
Choice C rationale
Nitroglycerin should be taken sublingually, not orally, for rapid absorption. Taking one tablet orally every hour up to 5 times is not the recommended dosing.
Choice D rationale
This is the correct dosing for nitroglycerin. If chest pain persists after the third dose, the client should seek immediate medical attention.
Correct Answer is A
Explanation
Choice A rationale
A patient with type 1 diabetes who has taken a high dose of insulin is at the highest risk for developing hypoglycemia. Insulin lowers blood glucose levels, and taking a high dose can cause the levels to drop too low.
Choice B rationale
A patient with type 2 diabetes who has not taken any medication is not at a high risk for developing hypoglycemia. Without medication, their blood glucose levels may be high, not low.
Choice C rationale
An elderly patient who is taking an antibiotic for an infection is not at a high risk for developing hypoglycemia. Antibiotics do not typically affect blood glucose levels.
Choice D rationale
A patient with metabolic syndrome who is taking a statin to lower cholesterol levels is not at a high risk for developing hypoglycemia. Statins do not typically affect blood glucose levels.
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