Nokea
A nurse is caring for a child who was admitted to the pediatric unit with infectious diarrhea. The nurse should be alert to what assessment finding as an indicator of dehydration?
- A. Labile BP
- B. Weak pulse
- C. Fever
- D. Diaphoresis
Correct Answer: B
Rationale: Weak pulse is a key sign of dehydration in children, along with thirst, dry mucous membranes, and poor skin turgor. Labile BP, fever, and diaphoresis are not specific to dehydration.
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An older adult patient tells the nurse that she had chicken pox as a child and is eager to be vaccinated against shingles. What should the nurse teach the patient about this vaccine?
- A. Vaccination against shingles is contraindicated in patients over the age of 80.
- B. Vaccination can reduce her risk of shingles by approximately 50%.
- C. Vaccination against shingles involves a series of three injections over the course of 6 months.
- D. Vaccination against shingles is only effective if preceded by a childhood varicella vaccination.
Correct Answer: B
Rationale: Zostavax reduces shingles risk by about 50% in adults over 60. It is a single injection, not contraindicated by age, and effective regardless of prior varicella vaccination.
A mother brings her 12 month-old son into the clinic for his measles-mumps-rubella (MMR) vaccination. What would the clinic nurse advise the mother about the MMR vaccine?
- A. Photophobia and hives might occur.
- B. There are no documented reactions to an MMR.
- C. Fever and hypersensitivity reaction might occur.
- D. Hypothermia might occur.
Correct Answer: C
Rationale: MMR vaccination may cause fever and hypersensitivity reactions. Photophobia, hives, and hypothermia are not typical, and reactions are well-documented.
A nursing home patient has been diagnosed with Clostridium difficile. What type of precautions should the nurse implement to prevent the spread of this infectious disease to other residents?
- A. Contact
- B. Droplet
- C. Airborne
- D. Positive pressure isolation
Correct Answer: A
Rationale: Clostridium difficile spreads via skin-to-skin contact or contaminated surfaces, requiring contact precautions. Droplet and airborne precautions are for respiratory pathogens, and positive pressure isolation is not applicable.
A 16-year-old male patient comes to the free clinic and is subsequently diagnosed with primary syphilis. What health problem most likely prompted the patient to seek care?
- A. The emergence of a chancre on his penis
- B. Painful urination
- C. Signs of a systemic infection
- D. Unilateral testicular swelling
Correct Answer: A
Rationale: Primary syphilis presents with a painless chancre at the infection site. Painful urination, systemic symptoms, or testicular swelling are not typical.
When a disease infects a host a portal of entry is needed for an organism to gain access. What has been identified as the portal of entry for tuberculosis?
- A. Integumentary system
- B. Urinary system
- C. Respiratory system
- D. Gastrointestinal system
Correct Answer: C
Rationale: Tuberculosis is transmitted via inhalation of airborne droplets, making the respiratory system the primary portal of entry.