Nokea
A nonimmunized child appears at the clinic with a visible rash. Which of the following observations indicates the child may have rubeola (measles)?
- A. Small blue-white spots are visible on the oral mucosa.
- B. The rash begins on the trunk and spreads outward.
- C. There is low-grade fever.
- D. The lesions have a "teardrop-on-a-rose-petal"? appearance.
Correct Answer: A
Rationale: The presence of small blue-white spots on the oral mucosa, known as Koplik's spots, is characteristic of measles (rubeola) infection. These spots typically appear on the buccal mucosa opposite the second molars, 1-2 days before the rash onset, and last until 2 days after the rash appears. While Koplik's spots are pathognomonic for measles, their absence does not rule out the diagnosis. Therefore, choice A is the correct answer. Choices B, C, and D are incorrect because the rash pattern, presence of low-grade fever, and characteristic appearance of lesions are not specific indicators of measles infection.
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A 23-year-old patient in the 27th week of pregnancy has been hospitalized on complete bed rest for 6 days. She experiences sudden shortness of breath, accompanied by chest pain. Which of the following conditions is the most likely cause of her symptoms?
- A. Myocardial infarction due to a history of atherosclerosis.
- B. Pulmonary embolism due to deep vein thrombosis (DVT).
- C. Anxiety attacks due to worries about her baby's health.
- D. Congestive heart failure due to fluid overload.
Correct Answer: B
Rationale: In a hospitalized patient on prolonged bed rest, the most likely cause of sudden onset shortness of breath and chest pain is pulmonary embolism. Pregnancy and prolonged inactivity both increase the risk of clot formation in the deep veins of the legs, known as deep vein thrombosis (DVT). These clots can dislodge and travel to the lungs, causing a pulmonary embolism. Myocardial infarction (Choice A) is less likely in a young patient without a significant history of atherosclerosis. Anxiety attacks (Choice C) may present with similar symptoms but are less likely in this context. Congestive heart failure (Choice D) is less probable given the acute onset of symptoms and absence of typical signs like peripheral edema in this case.
A patient with peripheral vascular disease is receiving discharge instructions. Which of the following information should be included?
- A. Walk barefoot whenever possible.
- B. Use a heating pad to keep feet warm.
- C. Avoid crossing the legs.
- D. Use antibacterial ointment to treat skin lesions prone to infection.
Correct Answer: C
Rationale: Patients with peripheral vascular disease should be advised to avoid crossing their legs as this can impede blood flow. Peripheral vascular disease, also known as arteriosclerosis obliterans, is primarily caused by atherosclerosis. Atherosclerosis results in the gradual progression of arterial occlusion due to the formation of atheromas. Crossed legs can further restrict blood flow, exacerbating the condition. Walking barefoot should be discouraged to prevent potential injuries to the feet. Using a heating pad can lead to burns and should be avoided to prevent thermal injuries. While using antibacterial ointment for skin lesions may be beneficial, it is not the priority instruction for patients with peripheral vascular disease.
While assessing a one-month-old infant, which of the findings does not warrant further investigation by the nurse?
- A. Abdominal respirations
- B. Inspiratory grunt
- C. Nasal flaring
- D. Cyanosis
Correct Answer: A
Rationale: Abdominal respirations in infants are considered normal due to the underdeveloped intercostal muscles. Infants rely more on their abdominal muscles to facilitate breathing since their intercostal muscles are not fully matured. Therefore, abdominal respirations do not typically require further investigation. Inspiratory grunt, nasal flaring, and cyanosis are findings that warrant additional assessment as they can indicate potential respiratory distress or other underlying health issues in infants. Inspiratory grunt may suggest respiratory distress, nasal flaring can be a sign of increased work of breathing, and cyanosis indicates poor oxygenation, all of which require prompt evaluation and intervention to ensure the infant's well-being.
An 18-year-old male patient informs the nurse that he isn't sure if he is homosexual because he is attracted to both genders. The nurse establishes a trusting relationship with the patient by saying:
- A. Don't worry. It's just a phase you will grow out of.
- B. Those are abnormal impulses. You should seek therapy.
- C. At your age, it is normal to be curious about both genders.
- D. Having questions about sexuality is normal. Have you noticed any changes in the way this makes you feel about yourself?
Correct Answer: C
Rationale: It is important for the nurse to validate the patient's concerns and provide a supportive environment. By acknowledging that it is normal for young adults to have questions about sexuality, the nurse helps the patient feel understood and accepted. This response encourages further discussion and exploration of the patient's feelings without judgment. Choice A dismisses the patient's concerns and implies that his feelings are not valid. Choice B stigmatizes the patient's feelings by labeling them as abnormal and suggests therapy without proper assessment. Choice D addresses the patient's feelings but lacks the validation and reassurance present in the correct answer, which is essential in building a trusting relationship with the patient.
A 32-year-old pregnant woman comes to the clinic for her prenatal visit. The nurse gathers data about her obstetric history, which includes 3-year-old twins at home and a miscarriage 10 years ago at 12 weeks gestation. How would the nurse accurately document this information?
- A. G4 T1 P0 A1 L2
- B. G3 T1 P0 A1 L2
- C. G3 T0 P1 A1 L2
- D. G4 T0 P1 A1 L2
Correct Answer: D
Rationale: The correct answer is G4 T1 P0 A1 L2. This documentation accurately represents the woman's obstetric history.
G4: She is currently pregnant (1), has twins (1), and had a miscarriage (1), totaling four pregnancies.
T1: She has had one pregnancy that resulted in the birth of her twins at term.
P0: She has not had any preterm births.
A1: She had one miscarriage at 12 weeks gestation.
L2: She has two living children (the twins). Therefore, the correct documentation reflects all aspects of her obstetric history as provided.