Nokea
A patient presents with vesicles covering the upper torso. Which of the following situations could cause this condition?
- A. Knife fight
- B. Auto accident
- C. Sunburn
- D. Fungal infection
Correct Answer: C
Rationale: Vesicles are fluid-filled blisters. In the context of the upper torso, the presentation of vesicles suggests a second-degree sunburn. Sunburn can cause blistering, leading to the formation of vesicles. Choice A, 'Knife fight,' does not align with the presentation of vesicles on the upper torso due to trauma. Choice B, 'Auto accident,' is more likely to cause abrasions or bruises rather than vesicles. Choice D, 'Fungal infection,' typically presents with other symptoms such as redness, itching, or scaling, but not vesicles on the upper torso.
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A 3-year-old child is seen in the health care clinic, and a diagnosis of encopresis is made. The nurse expects to provide teaching about which client problem?
- A. Odor
- B. Nausea
- C. Malaise
- D. Diarrhea
Correct Answer: A
Rationale: Encopresis is the repeated voluntary or involuntary passage of feces of normal or near-normal consistency in places not appropriate for that purpose according to the individual's own sociocultural setting. Signs of encopresis include evidence of soiled clothing, scratching or rubbing the anal area due to irritation, fecal odor without apparent awareness by the child, and social withdrawal. Teaching about odor is essential to address the issue of encopresis. Choices B, C, and D are incorrect because encopresis is not typically associated with nausea, malaise, or diarrhea. Therefore, teaching about these symptoms would not be relevant in the context of encopresis.
The healthcare professional calculates the IV flow rate for a patient receiving an antibiotic. The patient is to receive 100mL of the antibiotic over 30 minutes. The IV infusion set has a drop factor of 10 drops per milliliter. How many drops per minute should the healthcare professional set the IV to deliver?
- A. 11
- B. 19
- C. 26
- D. 33
Correct Answer: D
Rationale: To determine the drops per minute for the IV flow rate, you can use the formula: Drops Per Minute = (Milliliters to be infused x Drop Factor) / Time in Minutes. Substituting the given values, you get 100 mL x 10 drops/mL / 30 minutes = 33 drops per minute. Therefore, the correct answer is 33, as the healthcare professional should set the IV to deliver 33 drops per minute to infuse the antibiotic correctly. Choices A, B, and C are incorrect as they do not match the calculated drops per minute based on the provided values.
In a 24-year-old woman, the term used to define uterine bleeding in which there is no menstruation is:
- A. Oligomenorrhea
- B. Amenorrhea
- C. Menorrhagia
- D. Metrorrhagia
Correct Answer: B
Rationale: Amenorrhea is the correct term for the absence of menstrual periods in a woman of childbearing age. It is typically defined as no menstruation for at least three consecutive cycles or six months. Oligomenorrhea refers to infrequent or irregular menstrual periods rather than complete absence. Menorrhagia is characterized by excessive menstrual bleeding, not the absence of menstruation. Metrorrhagia involves irregular, acyclic bleeding between menstrual periods, which is different from the absence of menstruation.
Which of the following is NOT a warning sign that compensatory mechanisms in a patient in shock are failing?
- A. Increasing heart rate above normal for the patient's age.
- B. Absent peripheral pulses
- C. Decreasing level of consciousness
- D. Increasing blood pressure
Correct Answer: D
Rationale: In a patient in shock, increasing blood pressure is not a sign that compensatory mechanisms are failing. As shock progresses and compensatory mechanisms fail, systolic blood pressure will decrease, leading to hypotension, which is a late and ominous sign in these patients. Therefore, choices A, B, and C are warning signs of failing compensatory mechanisms in shock: an increasing heart rate above normal, absent peripheral pulses, and decreasing level of consciousness, respectively. An increasing blood pressure is not indicative of compensatory failure in shock; instead, it may be a sign of compensatory mechanisms still trying to maintain perfusion pressure.
The nurse has just admitted a client with severe depression. From which focus should the nurse identify a priority nursing diagnosis?
- A. Nutrition
- B. Elimination
- C. Activity
- D. Safety
Correct Answer: D
Rationale: In caring for a client with severe depression, safety is a critical priority. The nurse must address precautions to prevent suicide as part of the care plan. While nutrition, elimination, and activity are important aspects of care, safety takes precedence due to the immediate risk of harm associated with depression. Ensuring the client's safety by implementing measures to prevent self-harm or suicide is the priority intervention. Addressing nutrition, elimination, and activity can follow once the client's safety is assured.