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Which signs/symptoms should the nurse assess in the client who has been exposed to the anthrax bacillus via the skin?
- A. A scabby, clear fluid-filled vesicle.
- B. Edema, pruritus, and a 2-mm ulcerated vesicle.
- C. Irregular brownish-pink spots around the hairline.
- D. Tiny purple spots flush with the surface of the skin.
Correct Answer: B
Rationale: Cutaneous anthrax presents with edema, pruritus, and a small ulcerated vesicle that becomes necrotic. Scabby vesicles, brownish-pink spots, and purple spots are not typical.
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The nurse is providing discharge teaching for the client with intermaxillary wiring to repair a fractured mandible. Which statement by the client indicates teaching has been effective?
- A. Iced alcoholic drinks may be consumed by using a straw.
- B. Only one (1) food item should be consumed at one (1) time.
- C. Carbonated sodas should be limited to two (2) daily.
- D. Teeth can be brushed after tenderness and edema subside.
Correct Answer: D
Rationale: Brushing teeth after swelling subsides maintains oral hygiene safely. Alcohol, single food items, and soda limits are incorrect or unnecessary.
Which expected outcome is priority for the nurse who is caring for a client with chest trauma from a gunshot injury?
- A. The client will have an absence of pain.
- B. The client will maintain a BP of 90/60.
- C. The client will have symmetrical chest expansion.
- D. The client will maintain urine output of 30 mL/hr.
Correct Answer: C
Rationale: Symmetrical chest expansion ensures adequate ventilation, critical in chest trauma to prevent pneumothorax or hemothorax. Pain, low BP, and urine output are secondary.
The emergency department nurse writes the problem of 'ineffective coping' for a client who has been raped. Which intervention should the nurse implement?
- A. Encourage the client to take the 'morning-after' pill.
- B. Allow the client to admit guilt for causing the rape.
- C. Provide a list of rape crisis counselors.
- D. Discuss reporting the case to the police.
Correct Answer: C
Rationale: Rape crisis counselors provide specialized support for coping post-rape. Morning-after pill addresses pregnancy, guilt admission is harmful, and police reporting is client-driven.
The nurse caring for a client with sepsis writes the client diagnosis of 'alteration in comfort R/T chills and fever.' Which intervention should be included in the plan of care?
- A. Ambulate the client in the hallway every shift.
- B. Monitor urinalysis, creatinine level, and BUN level.
- C. Apply sequential compression devices to the lower extremities.
- D. Administer an antipyretic medication every four (4) hours PRN.
Correct Answer: D
Rationale: Antipyretics (e.g., acetaminophen) address fever and chills, improving comfort. Ambulation, lab monitoring, and compression devices address other sepsis concerns, not comfort.
The father of a child brought to the emergency department is yelling at the staff and obviously intoxicated. Which approach should the nurse take with the father?
- A. Talk to the father in a calm and low voice.
- B. Tell the father to wait in the waiting room.
- C. Notify the child’s mother to come to the ED.
- D. Call the police department to come and arrest him.
Correct Answer: A
Rationale: A calm, low voice de-escalates the situation, promoting safety. Waiting room relocation, notifying the mother, or police involvement may escalate or delay resolution.