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A client presents with the onset of a severe headache, fever, nuchal rigidity, and a petechial rash on arms and legs. The nurse recognizes the client is exhibiting symptoms of which condition?
- A. Rocky Mountain spotted fever.
- B. Intracerebral hemorrhage.
- C. Cerebrovascular accident (CVA).
- D. Meningococcal meningitis.
Correct Answer: D
Rationale: Meningococcal meningitis is characterized by severe headache, fever, nuchal rigidity, and a petechial rash, which are consistent with the client's symptoms.
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A patient is admitted to the hospital with symptoms consistent with a right hemisphere stroke. Which neurovascular assessment requires immediate intervention by the nurse?
- A. Pupillary changes to ipsilateral dilation.
- B. Left-sided facial drooping and dysphagia.
- C. Orientation to person and place only.
- D. Unequal bilateral hand grip strengths.
Correct Answer: A
Rationale: Pupillary changes to ipsilateral dilation indicate increased intracranial pressure, which is a life-threatening complication of stroke. The nurse should notify the physician and prepare for emergency measures.
The nurse is caring for a client with chemotherapy-induced mucositis who is describing soreness of the tongue and oral issues. Which is the best initial nursing action?
- A. Obtain a soft diet for the client.
- B. Encourage frequent mouth care.
- C. Cleanse the tongue and mouth with swabs.
- D. Administer a topical analgesic per protocol.
Correct Answer: B
Rationale: Encouraging frequent mouth care is the best initial action to prevent or reduce the severity of mucositis by removing plaque, bacteria, and debris, and moisturizing the oral tissues.
In assessing a client with ulcers on the lower extremity, which findings indicate that the ulcers are likely to be of venous, rather than arterial, origin?
- A. Irregular ulcer shapes and severe edema.
- B. Hairless lower extremities and cool feet.
- C. Black ulcers and dependent rubor.
- D. Absent pedal pulses and shiny skin.
Correct Answer: A
Rationale: Irregular ulcer shapes and severe edema are characteristic of venous ulcers, caused by impaired venous return and increased capillary pressure.
A client with diabetes mellitus is admitted with an upper respiratory infection. Which changes in blood glucose management should the client expect?
- A. Restriction of caloric intake.
- B. Fewer fingerstick glucose checks.
- C. Higher doses of insulin.
- D. Increased oral fluid intake.
Correct Answer: C
Rationale: Higher doses of insulin are needed to overcome increased insulin resistance caused by the infection and stress hormones, preventing hyperglycemia and ketoacidosis.
The healthcare provider prescribes 1 liter of 0.9% sodium chloride, USP intravenously (IV) to be infused over 10 hours for a client. How many mL/hr should the nurse program the infusion pump to deliver? (Enter numerical value only.)
- A. 100
Correct Answer: 100
Rationale: To deliver 1000 mL over 10 hours, the rate is calculated as 1000 mL / 10 hr = 100 mL/hr.