Nokea
A child comes to the clinic with a skin rash. The maculopapular lesions are distributed around the mouth and have honey-colored drainage. The caregiver states that the rash is getting worse and seems to spread with the child's scratching. Which of the following advisory comments should be given?
- A. The history and presentation might indicate chickenpox, a highly contagious disease.
- B. The lesions might indicate a noncontagious infection that does not require isolation.
- C. The history and presentation might indicate an infectious illness called impetigo.
- D. The lesions are not contagious unless others have open wounds or lesions themselves.
Correct Answer: C
Rationale: The scenario describes classic impetigo, which typically presents with maculopapular lesions around the mouth with honey-colored drainage, worsening with scratching. It is important to advise the caregiver that the history and presentation are indicative of impetigo, an infectious skin condition caused by bacteria. Treatment usually involves antibiotic therapy. Choice A is incorrect because chickenpox typically presents with a vesicular rash following a history of high fever. Choice B is incorrect as impetigo is contagious and requires precautions to prevent the spread of infection. Choice D is incorrect as impetigo is contagious irrespective of open wounds or lesions in others.
You may also like to solve these questions
While repositioning a comatose client, the nurse senses a tingling sensation as she lowers the bed. What action should she take?
- A. Unplug the bed's power source.
- B. Remove the client from the bed immediately.
- C. Notify the biomedical department at once.
- D. Turn off the oxygen.
Correct Answer: A
Rationale: The correct action for the nurse to take when sensing a tingling sensation while lowering the bed with a comatose client is to unplug the bed's power source. This should be the initial step as there may be a fault in the bed's grounding. Removing the client from the bed immediately is not safe until the electrical issue is resolved. Notifying the biomedical department is important but should come after ensuring the immediate safety of the client. Turning off the oxygen is not necessary unless there is a specific issue related to oxygen delivery, which is not indicated in this scenario.
To remove hard contact lenses from an unresponsive client, what should the nurse do?
- A. Gently irrigate the eye with an irrigating solution from the inner canthus outward
- B. Grasp the lens with a gentle pinching motion
- C. Don sterile gloves before attempting the procedure
- D. Ensure that the lens is centered on the cornea before gently manipulating the lids to release the lens
Correct Answer: D
Rationale: When removing hard contact lenses from an unresponsive client, the nurse should ensure that the lens is centered on the cornea before gently manipulating the lids to release the lens. This approach helps prevent scratching the cornea. Gently maneuvering the upper and lower eyelids assists in loosening the lens for easy removal. Options A, B, and C are incorrect because irrigating the eye, grasping the lens, or wearing sterile gloves are not recommended methods for removing hard contact lenses. It is crucial to handle the situation delicately to avoid causing harm or discomfort to the client.
The nurse uses prioritization to determine all of the following except:
- A. time allotment for certain tasks.
- B. appropriate interventions.
- C. treatment procedures.
- D. the need for client education.
Correct Answer: C
Rationale: The correct answer is C: "treatment procedures." Prioritization in nursing involves determining the order of importance or urgency of tasks. Treatment procedures are standards of care that need to be followed as defined by the facility or nursing unit. They are not typically subject to prioritization but are mandatory based on established protocols. Time allotment for certain tasks, appropriate interventions, and the need for client education are all aspects that can be influenced by prioritization. For instance, prioritizing tasks helps in managing time effectively, selecting the most suitable interventions, and identifying the necessity for client education as part of the care plan.
Which hormone in the urine is specifically indicative of pregnancy?
- A. estrogen
- B. progesterone
- C. testosterone
- D. human chorionic gonadotropin
Correct Answer: D
Rationale: Human chorionic gonadotropin is the hormone specifically indicative of pregnancy as it is produced by the placenta after implantation. It can be detected in urine and blood samples to confirm pregnancy. Estrogen and progesterone play crucial roles in the menstrual cycle and pregnancy but are not specific indicators of pregnancy on their own. Testosterone is a hormone primarily associated with male reproductive functions and is not directly related to pregnancy, making it an incorrect choice in this context.
The LPN is assisting the client with an NG tube with activities of daily living. Which of these statements would indicate a need for teaching reinforcement?
- A. "Since I'm not eating or drinking by mouth, I do not need to brush my teeth as often."?
- B. "I should remain sitting up at a 45-degree angle or higher for 30 minutes after a feeding."?
- C. "I can clean around the tube with water and mild soap."?
- D. "I should avoid using Vaseline around the nostril and tube."?
Correct Answer: A
Rationale: The correct answer is, "Since I'm not eating or drinking by mouth, I do not need to brush my teeth as often."? This statement indicates a need for teaching reinforcement because even when an NG tube is in place, the client should still brush their teeth twice daily. Good oral hygiene is essential to reduce the risk of introducing bacteria that may cause an infection. Choice B is incorrect because remaining sitting up at a 45-degree angle or higher for 30 minutes after a feeding is a correct statement regarding NG tube care, promoting proper digestion and reducing the risk of aspiration. Choice C is also incorrect because cleaning around the tube with water and mild soap is an appropriate practice to maintain cleanliness and prevent infection. Choice D is incorrect because advising to avoid using Vaseline around the nostril and tube is a proper instruction to prevent skin breakdown, occlusion of the tube, and potential aspiration of Vaseline into the lungs.