Nokea
A 54-year-old man presents with a temperature of 38.8°C (101.8°F), a racing heart, fatigue, and an upset stomach after spending an afternoon building a deck on a very hot, humid day. The physician assessing the man is performing a differential diagnosis as part of her assessment. Which finding would suggest fever rather than hyperthermia as a cause of the elevation in the man's temperature?
- A. Absence of sweating
- B. Shivering
- C. Lack of thirst
- D. Increased heart rate
Correct Answer: B
Rationale: Shivering is a physiological response to fever, as the body attempts to generate heat to increase the internal temperature. Hyperthermia, on the other hand, does not involve shivering. Absence of sweating (choice A) is more indicative of hyperthermia, as the body struggles to cool down without sweating. Lack of thirst (choice C) can be seen in both fever and hyperthermia. Increased heart rate (choice D) can occur in both fever and hyperthermia due to the body's attempt to regulate temperature.
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An infant is being administered an immunization. Which of the following provides an accurate description of an immunization?
- A. It should be administered to a pregnant woman prior to the infant's birth.
- B. It is the administration of an antigen to stimulate an antibody response.
- C. It produces many adverse reactions, particularly autism, in the infant.
- D. It protects the infant from exposure to infectious antibodies.
Correct Answer: B
Rationale: The correct answer is B. Immunization involves administering an antigen, such as a weakened or killed microorganism, to stimulate the immune system to produce an antibody response. This process helps the body recognize and remember specific pathogens, providing immunity against future infections. Choice A is incorrect because immunizations are administered to the infant directly, not to the pregnant woman before birth. Choice C is incorrect as there is no scientific evidence linking immunizations to autism. Choice D is incorrect as immunizations protect against infectious agents, not antibodies.
Following the administration of her annual influenza vaccination, a health care worker remains at the clinic for observation due to pain at the injection site. What should the nurse recommend?
- A. ASA
- B. Acetaminophen
- C. Meperidine (Demerol)
- D. Heat application
Correct Answer: B
Rationale: The correct recommendation for pain at the injection site after an influenza vaccination is Acetaminophen. Acetaminophen is a suitable choice for managing mild to moderate pain and fever commonly associated with vaccinations. Choice A, ASA (aspirin), is not recommended due to the risk of Reye's syndrome in children and teenagers following viral illnesses. Choice C, Meperidine (Demerol), is a potent opioid analgesic and is not typically indicated for mild pain relief. Choice D, heat application, is not the standard recommendation for pain at an injection site and may not provide adequate relief.
What is the characteristic of the condition of leukemia?
- A. A benign growth of skin cells
- B. A malignant growth of skin cells
- C. A malignant growth of white blood cells
- D. A benign growth of white blood cells
Correct Answer: C
Rationale: The correct answer is C: 'A malignant growth of white blood cells.' Leukemia is a type of cancer that affects the blood and bone marrow, leading to an overproduction of abnormal white blood cells. These cells are malignant and impair the normal function of healthy blood cells. Choices A, B, and D are incorrect because leukemia does not involve skin cells or benign growths; instead, it specifically refers to the abnormal proliferation of white blood cells.
A female client with bone metastases secondary to lung cancer is admitted for palliative radiation treatment and pain control. The client is currently experiencing pain that she rates at 9 out of 10. Which of the following nonpharmacologic treatments is most likely to be a useful and appropriate supplement to pharmacologic analgesia at this point?
- A. Teaching the client guided imagery and meditation
- B. Initiating neurostimulation
- C. Heat therapy
- D. Relaxation and distraction
Correct Answer: D
Rationale: In the scenario described, the client is experiencing high pain levels, rated at 9 out of 10. Relaxation and distraction techniques are effective nonpharmacologic interventions for managing pain. Teaching the client guided imagery and meditation (Choice A) can also be beneficial; however, in this acute situation of severe pain, relaxation and distraction techniques are more likely to provide immediate relief. Initiating neurostimulation (Choice B) and heat therapy (Choice C) may not be suitable for immediate pain relief in this scenario and are not as commonly used for managing high pain levels in palliative care settings.
What is the common denominator of all forms of heart failure?
- A. Pulmonary edema
- B. Jugular venous distention
- C. Peripheral edema
- D. Reduced cardiac output
Correct Answer: D
Rationale: The correct answer is D: Reduced cardiac output. All forms of heart failure share the common denominator of reduced cardiac output, which leads to inadequate tissue perfusion. Pulmonary edema (choice A) is a consequence of heart failure but not the common denominator. Jugular venous distention (choice B) and peripheral edema (choice C) are signs of heart failure but do not represent the common denominator shared by all forms.