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A clinic nurse is assessing a client who has measles. Which of the following findings should the nurse expect?
- A. Koplik spots inside the mouth
- B. Persistent low-grade temperature
- C. Muscle aches and tenderness
- D. Rash confined to the trunk of the body
Correct Answer: A
Rationale: The correct answer is A: Koplik spots inside the mouth. These are small, white spots surrounded by a red ring that appear on the buccal mucosa. This finding is characteristic of measles and typically precedes the onset of the rash. Koplik spots are highly specific to measles and can aid in early diagnosis. Persistent low-grade temperature (B) and muscle aches and tenderness (C) are common symptoms of many viral illnesses, including measles, but they are not specific to measles. The rash associated with measles typically starts on the face and head before spreading to the trunk and extremities, so a rash confined to the trunk (D) would not be expected in measles.
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A home health nurse is assessing a client who has AIDS. Which of the following responses by the client indicates a risk for suicide?
- A. I'm afraid of experiencing pain near the end.
- B. I know that everything will be better soon.
- C. I am relying more and more on my partner for support.
- D. I don't want to lose control of my ability to make decisions.
Correct Answer: B
Rationale: The correct answer is B: "I know that everything will be better soon." This response indicates a risk for suicide as it reflects a sense of hopelessness or feeling that things will not improve. This mindset is often associated with suicidal ideation.
A: Fear of pain near the end is a common concern in terminal illnesses but does not directly indicate suicide risk.
C: Relying on a partner for support can be a coping mechanism and does not necessarily indicate suicide risk.
D: Desire to maintain decision-making control is a sign of autonomy and does not directly indicate suicide risk.
In summary, choice B is correct as it suggests a lack of hope for the future, while the other choices do not directly indicate a risk for suicide.
A school nurse is assessing a child who has been stung by a bee. The child's hand is swelling, and the nurse notes that the child is allergic to insect stings. Which of the following findings should the nurse expect if the child develops anaphylaxis? (SATA)
- A. Bradycardia
- B. Nausea
- C. Hypertension
- D. Urticaria
- E. Stridor
Correct Answer: B, D, E
Rationale: Correct Answer: B, D, E
Rationale:
1. Nausea: Anaphylaxis can cause gastrointestinal symptoms like nausea due to the release of inflammatory mediators.
2. Urticaria: Anaphylaxis commonly presents with hives (urticaria) as a manifestation of allergic reaction.
3. Stridor: Anaphylaxis can lead to upper airway swelling, causing stridor due to compromised breathing.
Summary of Incorrect Choices:
A. Bradycardia: Anaphylaxis typically causes tachycardia due to the body's response to the allergen.
C. Hypertension: Anaphylaxis usually results in hypotension due to vasodilation and increased vascular permeability.
A school nurse is planning safety education for a group of adolescents. The nurse should give priority to which of the following topics as the leading cause of death for this age group?
- A. Sports injury prevention
- B. Motor vehicle safety
- C. Substance abuse prevention
- D. Gun safety
Correct Answer: B
Rationale: The correct answer is B: Motor vehicle safety. Adolescents are at a higher risk of motor vehicle accidents, making it the leading cause of death in this age group. This is due to factors like inexperience, risk-taking behaviors, and distractions while driving. Sports injury prevention (A) is important but not the leading cause of death. Substance abuse prevention (C) is significant but not the primary cause of death. Gun safety (D) is also crucial but not as prevalent as motor vehicle accidents.
A nurse is preparing an educational program about breastfeeding for a group of new parents. The nurse should use which of the following instructional strategies to promote psychomotor learning?
- A. Review flashcards that identify holding technique with the group
- B. Show the group a video on breastfeeding techniques
- C. Facilitate a discussion group about the benefits of breastfeeding
- D. Provide dolls for the group to demonstrate proper positioning
Correct Answer: D
Rationale: The correct answer is D because providing dolls for the group to demonstrate proper positioning promotes psychomotor learning by engaging them in hands-on practice. This allows participants to physically practice and internalize the correct techniques, enhancing muscle memory and skill acquisition. The other choices lack the hands-on component required for psychomotor learning. A: Flashcards are visual aids that may help with cognitive learning but do not involve physical practice. B: Watching a video is passive learning and does not actively engage participants in practicing skills. C: Facilitating a discussion focuses on cognitive understanding rather than physical practice.
A nurse in a mobile health clinic is caring for a client who requires a tetanus immunization and is accompanied by his daughter. The client does not speak the same language as the nurse. Which of the following actions should the nurse take?
- A. Have the client's daughter communicate information about the procedure
- B. Arrange for a member of the client's community to interpret the teaching
- C. Identify the client's spoken dialect prior to contacting an interpreter
- D. Use professional terminology when providing education prior to the procedure
Correct Answer: C
Rationale: The correct answer is C: Identify the client's spoken dialect prior to contacting an interpreter. This is the most appropriate action because it ensures effective communication by matching the client with an interpreter who speaks the same dialect. This step shows cultural sensitivity and respects the client's language preference, promoting trust and understanding.
Other choices are incorrect:
A: Having the client's daughter communicate may not guarantee accurate information exchange due to potential language barriers.
B: Arranging for a community member to interpret may not ensure confidentiality or accuracy in communication.
D: Using professional terminology without ensuring understanding may lead to confusion and hinder effective communication.