A nurse is reinforcing teaching about self-care with an adolescent client who has infectious mononucleosis with splenomegaly.
Which of the following statements by the client indicates an understanding of the teaching?
“I will take an antibiotic for the next 10 days.”
“I will not play soccer until my doctor tells me I can.”
“I will need to get a varicella booster in 1 month.”
“I will expect the whites of my eyes to turn yellow.”
The Correct Answer is B
“I will not play soccer until my doctor tells me I can.” This statement indicates that the client understands the risk of splenic rupture due to splenomegaly and the need to avoid contact sports until the spleen returns to normal size.
Choice A is wrong because antibiotics are not effective for infectious mononucleosis, which is caused by a virus.
Choice C is wrong because varicella booster is not related to infectious mononucleosis and there is no evidence that the client needs it.
Choice D is wrong because jaundice (yellowing of the eyes and skin) is not a common manifestation of infectious mononucleosis and may indicate another condition such as hepatitis.
Normal ranges for spleen size are 7 to 14 cm in length and 3 to 4 cm in thickness.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Clean the cannula prongs daily.
This is because the nasal cannula can become contaminated with bacteria and mucus, which can cause infection and irritation of the nasal mucosa. Cleaning the cannula prongs daily with soap and water can prevent these complications.
Choice A is wrong because humidifiers can help moisten the dry oxygen and prevent nasal dryness and bleeding. Humidifiers should be used for oxygen flow rates higher than 4 L/min.
Choice B is wrong because the cannula prongs should be positioned curving downward in the nose, not upward. This allows for better alignment with the natural direction of airflow and reduces the risk of dislodgement.
Choice D is wrong because keeping the oxygen tubing off the floor is not a specific action for nasal cannula use. It is a general safety measure to prevent tripping and contamination of the tubing.
Correct Answer is A
Explanation
A. Frequent swallowing after a tonsillectomy may indicate postoperative bleeding. The nurse should check the back of the throat with a pen light to assess for signs of hemorrhage.
B. While obtaining vital signs is important, it does not directly address the concern of potential bleeding.
C. Administering analgesia is appropriate for pain management but does not address the priority concern of bleeding.
D. Offering water could potentially worsen bleeding if it is occurring and should not be the first action.
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