Nokea
A client is seen for testing to rule out Rocky Mountain Spotted Fever. Which of the following signs or symptoms is associated with this condition?
- A. Fever and rash
- B. Circumoral cyanosis
- C. Elevated glucose levels
- D. All of the above
Correct Answer: A
Rationale: The correct answer is 'Fever and rash.' Rocky Mountain Spotted Fever (RMSP) is caused by the R. rickettsii pathogen, which damages blood vessels. Patients with RMSP typically present with fever, edema, and a rash that initially appears on the hands and feet before spreading across the body. The disease manifests following a tick bite. Choice A is correct as fever and rash are key indicators of RMSP. Circumoral cyanosis (choice B) is not typically associated with RMSP; it refers to a bluish discoloration around the mouth and is more indicative of oxygen deprivation. Elevated glucose levels (choice C) are not specific signs of RMSP. Therefore, choice D, 'All of the above,' is incorrect since only choice A, 'Fever and rash,' is associated with Rocky Mountain Spotted Fever.
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The nurse is caring for a 10-year-old on admission to the burn unit. One assessment parameter that will indicate that the child has adequate fluid replacement is:
- A. Urinary output of 30 ml per hour
- B. No complaints of thirst
- C. Increased hematocrit
- D. Good skin turgor around burn
Correct Answer: A
Rationale: For a child of this age, this is adequate output, yet does not suggest overload. Disruption of sodium-ATPase activity presumably causes an intracellular sodium shift which contributes to hypovolemia and cellular edema. Heat injury also initiates the release of inflammatory and vasoactive mediators. These mediators are responsible for local vasoconstriction, systemic vasodilation, and increased transcapillary permeability. Increase in transcapillary permeability results in a rapid transfer of water, inorganic solutes, and plasma proteins between the intravascular and interstitial spaces.
A client with asthma has low-pitched wheezes present in the final half of exhalation. One hour later, the client has high-pitched wheezes extending throughout exhalation. This change in assessment indicates to the nurse that the client:
- A. Has increased airway obstruction.
- B. Has improved airway obstruction.
- C. Needs to be suctioned.
- D. Exhibits hyperventilation.
Correct Answer: B
Rationale: The change from low-pitched wheezes to high-pitched wheezes indicates a shift from larger to smaller airway obstruction, suggesting increased narrowing of the airways. This change signifies a progression or worsening of the airway obstruction. The absence of evidence of secretions does not support the need for suctioning. Hyperventilation is characterized by rapid and deep breathing, which is not indicated by the information provided in the question.
A clinic nurse interviews a parent who is suspected of abusing her child. Which of the following characteristics is the nurse least likely to find in an abusing parent?
- A. Low self-esteem
- B. Unemployment
- C. Self-blame for the injury to the child
- D. Single status
Correct Answer: C
Rationale: The profile of a parent at risk of abusive behavior includes a tendency to blame the child or others for the injury sustained. Abusers typically blame others, especially their partners, for the mistakes in their lives. This is related to hypersensitivity, but they are not necessarily alike. This occurs because most abusive people don't hold themselves as being accountable for the actions they commit. Instead, they'll try to shift the blame to the person that they have abused and somehow say they "deserved it"? or that they were forced into a corner.
What should the nurse in the emergency department do first for a new patient who is vomiting blood?
- A. Insert a large-gauge IV catheter.
- B. Draw blood for coagulation studies.
- C. Check blood pressure (BP), heart rate, and respirations.
- D. Place the patient in the supine position.
Correct Answer: C
Rationale: The nurse's initial action should focus on assessing the patient's hemodynamic status by checking vital signs like blood pressure, heart rate, and respirations. This assessment will help determine the patient's immediate needs and guide further interventions. Drawing blood for coagulation studies and inserting an IV catheter are important steps, but they can follow the initial assessment of vital signs. Placing the patient in the supine position can be risky without first assessing the patient's vital signs, as aspiration is a concern. Therefore, assessing vital signs is the priority to ensure appropriate and timely care for the patient.
To palpate the liver during a head-to-toe physical assessment, the nurse should
- A. put pressure on the biopsy site using a sandbag
- B. elevate the head of the bed to facilitate breathing
- C. place the patient on the right side with the bed flat
- D. check the patient's post-biopsy coagulation studies
Correct Answer: C
Rationale: To palpate the liver effectively during a head-to-toe physical assessment, the patient should be positioned on the right side with the bed flat. This position helps to splint the biopsy site and allows for proper palpation of the liver. Elevating the head of the bed has no direct relevance to palpating the liver. Checking coagulation studies is done before the biopsy and is unrelated to palpation. Putting pressure on the biopsy site using a sandbag is not an appropriate way to facilitate liver palpation as it does not provide the necessary support and stabilization needed for the procedure.