Nokea
A nurse is collecting data from a client who has contact dermatitis of the neck and upper chest. Which of the following findings should the nurse expect?
- A. Reports of exposure to a skin irritant
- B. Elevated temperature
- C. Denial of pruritus
- D. Reports of joint discomfort
Correct Answer: A
Rationale: Reports of exposure to a skin irritant: This finding is consistent with contact dermatitis, as it typically occurs due to exposure to irritants or allergens. Therefore, it is an expected finding. Elevated temperature: Elevated temperature is not typically associated with contact dermatitis unless there is a secondary infection. It is not a typical finding in uncomplicated contact dermatitis. Denial of pruritus: Pruritus, or itching, is a common symptom of contact dermatitis. Clients with contact dermatitis often experience itching or discomfort in the affected area. Therefore, denial of pruritus would be an unexpected finding. Reports of joint discomfort: Joint discomfort is not typically associated with contact dermatitis. Contact dermatitis primarily affects the skin and does not usually involve the joints. Therefore, reports of joint discomfort would be an unexpected finding.
You may also like to solve these questions
A nurse is providing teaching to a parent of a child who has celiac disease. The nurse should include which of the following as an acceptable food choice for this child?
- A. Barley
- B. Rye
- C. Rice
- D. Wheat
Correct Answer: C
Rationale: Barley: Barley is a grain that contains gluten. Foods made from barley, such as barley flour or barley-based products like bread, cereal, or beer, should be avoided by individuals with celiac disease because gluten can trigger an immune response that damages the small intestine. Rye: Similar to barley, rye is another grain that contains gluten. Foods made from rye, such as rye bread or rye-based cereals, should also be avoided by individuals with celiac disease because they can trigger adverse reactions due to gluten. Rice: Rice is a gluten-free grain and is safe for individuals with celiac disease to consume. It does not contain gluten proteins that can cause intestinal damage or trigger immune responses in those with gluten sensitivity or celiac disease. Wheat: Wheat is a major source of gluten and should be strictly avoided by individuals with celiac disease. Foods made from wheat, such as wheat bread, pasta, or baked goods, can lead to symptoms and intestinal damage in individuals with gluten intolerance or celiac disease.
A nurse is caring for a child who is experiencing a seizure. Which of the following actions should the nurse take?
- A. Place the child in a side-lying position.
- B. Restrain the child's arms.
- C. Elevate the child's legs on a pillow.
- D. Insert a padded tongue blade into the child's mouth.
Correct Answer: A
Rationale: Place the child in a side-lying position. This is the correct action to take during a seizure to prevent aspiration and maintain an open airway. Placing the child in a side-lying position helps to prevent choking or aspiration if vomiting occurs and allows saliva or other fluids to drain out of the mouth instead of being inhaled into the lungs. Restrain the child's arms. Restraining the child's arms is not recommended during a seizure. It can potentially cause injury to the child or the person trying to restrain them. It may also exacerbate muscle spasms and increase the risk of injury during the seizure. Elevate the child's legs on a pillow. Elevating the child's legs on a pillow is not necessary during a seizure and is not a recommended intervention. It does not address the immediate needs of the child during a seizure, such as maintaining an open airway and preventing injury. Insert a padded tongue blade into the child's mouth. Inserting anything into the child's mouth during a seizure, including a tongue blade, is strongly discouraged. It can cause injury to the child's teeth, gums, or oral tissues and increase the risk of choking or aspiration. It may also result in the nurse getting bitten during the seizure. Maintaining a clear airway and ensuring the child's safety are the priorities during a seizure, and inserting objects into the mouth can interfere with these goals.
A nurse is caring for a toddler who has intussusception. Which of the following manifestations should the nurse expect?
- A. Drooling
- B. Increased appetite
- C. Mucus in stools
- D. Jaundice
Correct Answer: C
Rationale: Drooling - Drooling is not typically associated with intussusception. Intussusception is a condition where one portion of the intestine telescopes into another, leading to bowel obstruction and subsequent symptoms such as abdominal pain, vomiting, and 'currant jelly' stools. Increased appetite - Increased appetite is unlikely in a toddler with intussusception. Instead, affected toddlers may experience symptoms such as abdominal pain, vomiting, and lethargy, which can lead to decreased appetite. Mucus in stools - Mucus in stools is a characteristic finding in intussusception. As the telescoping of the intestine causes irritation and inflammation, mucus may be passed in the stool along with blood and, in some cases, a characteristic 'currant jelly' appearance. Jaundice - Jaundice is not a typical manifestation of intussusception. It may be present in conditions affecting the liver or bile ducts, such as biliary atresia or obstructive jaundice, but it is not a direct symptom of intussusception.
A nurse is caring for a child who has tinea pedis. The child's parent asks the nurse what this infection is commonly called. The nurse should respond with which of the following common names?
- A. Shingles
- B. Athlete's foot
- C. Fever blister
- D. Pinworms
Correct Answer: B
Rationale: Shingles: This is a viral infection caused by the varicella-zoster virus, which also causes chickenpox. It typically manifests as a painful rash that develops into fluid-filled blisters. Athlete's foot: This is a fungal infection of the skin on the feet, particularly between the toes. It causes itching, burning, and cracked, flaking skin. Fever blister: Also known as a cold sore, this is a viral infection caused by the herpes simplex virus. It typically appears as a cluster of small, fluid-filled blisters on or around the lips. Pinworms: This is a parasitic infection caused by tiny, white worms that infect the intestines. It commonly causes anal itching, particularly at night, due to the female worms laying eggs around the anal area.
A nurse is caring for a child who is having a seizure. Which of the following actions should the nurse take? (Select all that apply.)
- A. Place a tongue depressor in the child's mouth.
- B. Restrain the child.
- C. Clear the area of hard objects.
- D. Loosen restrictive clothing.
- E. Place the child in a prone position
Correct Answer: C,
Rationale: A. Place a tongue depressor in the child's mouth: This is an incorrect action. Placing a tongue depressor or any other object in the child's mouth during a seizure can cause injury to the child's mouth, teeth, or airway. It may also increase the risk of choking. It's a common misconception that people can swallow their tongues during a seizure, but this is not true. It's important to keep the child's mouth clear of objects and allow the seizure to run its course. B. Restrain the child: This is also an incorrect action. Restraint can cause further injury to the child and increase agitation, which may worsen the seizure. It's important to allow the child to move freely during a seizure while taking steps to ensure their safety, such as clearing the area of objects and protecting the head from injury. C. Clear the area of hard objects: This is a correct action. Removing hard objects from the area helps prevent injury to the child during a seizure. Objects such as furniture corners or sharp items can pose a risk if the child thrashes or moves unpredictably during the seizure. D. Loosen restrictive clothing: This is also a correct action. During a seizure, it's important to ensure that the child's clothing is not too tight or restrictive. Loosening clothing, especially around the neck and chest area, helps ensure adequate airflow and prevents restriction of movement during the seizure. E. Place the child in a prone position: This is an incorrect action. Placing the child in a prone (face-down) position during a seizure can increase the risk of airway obstruction and make it more difficult for the child to breathe. Instead, the child should be placed on their side (recovery position) to help maintain an open airway and prevent aspiration if vomiting occurs.