An adult patient has presented to the health clinic with a complaint of a firm, painless cervical lymph node. The patient denies any recent infectious diseases. What is the nurse's most appropriate response to the patient's complaint?

Correct Answer: B

Rationale: The correct answer is B: Promptly refer the patient for medical assessment. A firm, painless cervical lymph node in an adult without recent infectious diseases raises concern for potential serious underlying conditions such as malignancy. Referring the patient for medical assessment allows for proper evaluation, diagnosis, and timely intervention if needed. Calling 911 (choice A) is not necessary as the patient is not in immediate life-threatening danger. Facilitating a radiograph (choice C) may not provide sufficient information for a definitive diagnosis. Encouraging the patient to track the size and wait a week (choice D) can delay necessary medical evaluation and potentially worsen the condition if it is indeed concerning.

Correct Answer: B

Rationale: The correct answer is B: Headache. Alteplase is a thrombolytic medication that can increase the risk of bleeding, including intracranial bleeding, leading to headaches. Monitoring for headaches is crucial to detect any signs of bleeding. Bronchodilation (A) is not a common adverse effect of alteplase. Edema (C) and hypertension (D) are also not typically associated with alteplase therapy. Monitoring for headache is essential for early detection of potentially life-threatening complications.

Correct Answer: B

Rationale: Rationale: Aminocaproic acid is used to manage bleeding complications associated with thrombolytic therapy, like alteplase. In case of severe adverse reaction such as uncontrolled bleeding, aminocaproic acid can help by inhibiting fibrinolysis. Vitamin K (A) is not used for this purpose. Protamine (C) is used to reverse heparin anticoagulation, not for thrombolytic therapy. Deferoxamine (D) is used for iron toxicity, not related to thrombolytic therapy. Thus, having aminocaproic acid available is crucial for managing potential adverse reactions during alteplase therapy.

Correct Answer: B

Rationale: Clopidogrel is contraindicated for clients with peptic ulcer disease due to its antiplatelet effect, which can increase the risk of gastrointestinal bleeding. Myocardial infarction, pancreatitis, and myasthenia gravis are not direct contraindications for clopidogrel. Myocardial infarction can actually be an indication for clopidogrel use to prevent further cardiovascular events. Pancreatitis and myasthenia gravis are not known to have specific contraindications with clopidogrel.

Correct Answer: B

Rationale: The correct answer is B: Reticulocyte count. Reticulocytes are immature red blood cells. In megaloblastic anemia, there is a decrease in red blood cell production due to a deficiency in folic acid. Monitoring reticulocyte count helps determine if the folic acid treatment is increasing red blood cell production. A: Amylase level is not relevant to monitoring the effectiveness of folic acid in treating megaloblastic anemia. C: C-reactive protein is a marker for inflammation and not specific to monitoring anemia treatment. D: Creatinine clearance is used to assess kidney function, not the effectiveness of folic acid in treating anemia.