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The child has pertussis.
A nurse is collecting data from a child who has pertussis. Which of the following manifestations should the nurse expect?
- A. Facial erythema
- B. Peeling of the hands and feet
- C. Fever
- D. Beefy, red tongue
Correct Answer: C
Rationale: Fever is a common symptom of pertussis.
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The client becomes combative and threatens other clients and staff.
A nurse is working with a client who becomes combative and threatens other clients and staff. Which of the following actions should the nurse take?
- A. Stand in front of the client to block them from others in the room.
- B. Apply restraints according to the facility's standing order.
- C. Ensure there are enough staff members available for assistance.
- D. Obtain a PRN prescription for restraints from the provider.
Correct Answer: C
Rationale: Ensuring staff availability ensures safety without immediate restraint use.
A nurse is contributing to the plan of care for a client who is experiencing delirium. Which of the following interventions should the nurse recommend?
- A. Offer the client several choices at mealtimes.
- B. Alternate daily caregivers.
- C. Avoid discussing the client's fears.
- D. Remind the client of the day and time often.
Correct Answer: D
Rationale: Frequent orientation to time reduces confusion in delirium.
A nurse is applying a belt restraint to a client who has become physically aggressive. Which of the following actions should the nurse take?
- A. Place the client in a sitting position.
- B. Tie the restraint to the railing of the client's bed.
- C. Ensure the restraint is placed across the client's chest.
- D. Apply the restraint under the client's clothes.
Correct Answer: A
Rationale: Placing the client in a sitting position ensures safety and proper restraint application.
A nurse is contributing to the plan of care for a newly admitted client who has anorexia nervosa. Which of the following interventions should the nurse include?
- A. Monitor the client for 1 hr after meals.
- B. Weigh the client every 2 days.
- C. Check the client's vital signs two times per week.
- D. Allow the client 2 hr to finish meals.
Correct Answer: A
Rationale: Monitoring for 1 hour after meals prevents purging, a key intervention for anorexia.
A nurse is collecting data from a client who has a long leg cast on his left leg. Which of the following findings is the priority?
- A. Diminished pulses on the affected extremity
- B. Ecchymosis on the inner left thigh
- C. Client report of muscle spasms of the left leg
- D. One fingerbreadth of space between the cast and the skin
Correct Answer: A
Rationale: Diminished pulses suggest vascular compromise, a priority concern.