Nokea
A 5-year-old child is admitted with a fever and rash. The nurse suspects scarlet fever. Which assessment finding supports this diagnosis?
- A. Strawberry tongue
- B. Koplik spots
- C. Vesicular rash
- D. Pustules on the trunk
Correct Answer: A
Rationale: Strawberry tongue is a characteristic sign of scarlet fever, caused by group A Streptococcus, aiding in diagnosis confirmation.
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You are a hospice nurse who, as part of your role, does follow up counseling and care for the significant others of deceased spouses for one year after their loss. Whose theory of grief and loss would you most likely integrate into your practice as you perform this role?
- A. Engel's theory
- B. Kubler Ross' theory
- C. Lewin's theory
- D. Warden's theory
Correct Answer: B
Rationale: Kubler-Ross' theory of the five stages of grief (denial, anger, bargaining, depression, acceptance) is widely used in hospice care to guide counseling for grieving significant others.
The Patient Self Determination Act of the United States protects clients in terms of their rights to what? Select all that apply.
- A. Privacy and to have their medical information confidential unless the client formally approves the sharing of this information with others such as family members.
- B. Make healthcare decisions and to have these decisions protected and communicated to others when they are no longer competent to do so.
- C. Be fully informed about all treatments in term of their benefits, risks and alternatives to them so the client can make a knowledgeable and informed decision about whether or not to agree to having it
- D. Make decisions about who their health care provider is without any coercion or undue influence of others including healthcare providers.
Correct Answer: B,C
Rationale: The Patient Self Determination Act (PSDA) of 1990 ensures that patients are informed of their rights to make decisions about their healthcare, including the right to accept or refuse treatment and to formulate advance directives . It also requires that patients be informed about treatment options, risks, benefits, and alternatives to make informed decisions . Option A relates to HIPAA, not the PSDA, and option D is not a specific right protected under the PSDA.
The nurse providing care to a client with a leg fracture ensures that which intervention is first implemented before the fracture is reduced in the casting room?
- A. Obtaining an anesthesia consent
- B. Administering an opioid analgesic
- C. Notifying the operating room staff
- D. Obtaining an informed consent for treatment
Correct Answer: D
Rationale: Before a fracture is reduced, an informed consent for treatment is needed. The nurse should reinforce explanations according to the client's needs and ability to understand. Administration of anesthesia would only be done in the operating room for open reduction of fractures. Closed reductions may be done in the emergency department without anesthesia. An analgesic would be administered as prescribed because the procedure is painful, but the informed consent form must be obtained before administering the medication.
A client with severe major depression states, 'My heart has stopped and my blood is black ash.' The nurse interprets this statement to be evidence of which of the following?
- A. Hallucination.
- B. Illusion.
- C. Delusion.
- D. Paranoia.
Correct Answer: C
Rationale: The client's statement reflects a false, fixed belief that is not based in reality, which is characteristic of a delusion. Hallucinations involve sensory perceptions, illusions are misinterpretations of stimuli, and paranoia involves suspicion, none of which fit this scenario.
A client with a history of rheumatoid arthritis is prescribed hydroxychloroquine (Plaquenil). The nurse should instruct the client to:
- A. Have regular eye exams.
- B. Take the medication on an empty stomach.
- C. Avoid calcium-rich foods.
- D. Stop the medication if joint pain resolves.
Correct Answer: A
Rationale: Hydroxychloroquine can cause retinal toxicity, requiring regular eye exams.