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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 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 public health nurse is responding to a suspected anthrax exposure at a workplace. Which action should the nurse take?
- A. Alert the family members of coworkers about possible exposure to anthrax
- B. Place the employee under quarantine for 14 days
- C. Refer coworkers who might have been exposed to a provider for prophylactic antibiotics
- D. Instruct the client to wear a mask at work
Correct Answer: C
Rationale: The correct action for the public health nurse is to refer coworkers who might have been exposed to a provider for prophylactic antibiotics (Choice C). This is because prophylactic antibiotics can help prevent the development of anthrax infection after exposure. Alerting family members (Choice A) is unnecessary as the focus should be on the exposed individuals. Quarantine (Choice B) may not be necessary if the individuals receive prophylactic treatment. Instructing the client to wear a mask (Choice D) is not effective in preventing anthrax transmission.
A home health nurse is planning the initial home visit for a client who has dementia and lives with his adult son's family. Which of the following actions should the nurse take first during the visit?
- A. Encourage the family to join a support group
- B. Provide the family with information about respite care
- C. Educate the family regarding the progression of dementia
- D. Engage the family in informal conversation
Correct Answer: D
Rationale: The correct answer is D: Engage the family in informal conversation. This is the first action the nurse should take during the initial visit because building rapport and establishing trust with the family is crucial in the care of a client with dementia. By engaging in informal conversation, the nurse can observe family dynamics, assess the family's understanding of the client's condition, and gather valuable information about the client's daily routine and needs. This lays the foundation for effective communication and collaboration moving forward.
A: Encouraging the family to join a support group can be beneficial but should come after establishing rapport and assessing the family's needs.
B: Providing information about respite care is important, but it is not the priority during the initial visit.
C: Educating the family about the progression of dementia is important, but it should be done after building rapport and assessing their current understanding.
A community health nurse is planning a smoking cessation class. Which of the following factors will have the greatest effect on the success of the class?
- A. Presenter's teaching strategies
- B. Presenter's credibility
- C. Client's motivation
- D. Client's education level
Correct Answer: C
Rationale: The correct answer is C: Client's motivation. Motivation plays a crucial role in behavior change like quitting smoking. Without intrinsic motivation, clients may not fully engage in the class or follow through with quitting. Presenter's teaching strategies (A) and credibility (B) are important but not as impactful as client motivation. Client's education level (D) may influence comprehension but not motivation.
A faith community nurse is preparing to meet with the family of an adolescent who has leukemia. Which of the following actions should the nurse plan to take?
- A. Focus the discussion on the adolescent's future career plans.
- B. Determine how the adolescent's health has affected family roles.
- C. Ask another family from the same faith congregation to attend the meeting for support.
- D. Direct conversation to the parents to avoid embarrassing the adolescent.
Correct Answer: B
Rationale: The correct answer is B: Determine how the adolescent's health has affected family roles. This is important because the nurse needs to understand the impact of the adolescent's illness on the family dynamics and roles. By assessing this, the nurse can provide appropriate support and resources to help the family cope effectively.
Choice A is incorrect because focusing on the adolescent's future career plans may not address the immediate concerns and emotional needs of the family facing a health crisis.
Choice C is incorrect as involving another family may not be appropriate without the consent of the adolescent and their family.
Choice D is incorrect because directing the conversation solely to the parents may exclude the adolescent from being an active participant in their own care and may not address their unique needs.