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A public health nurse is preparing an educational handout about rubella, commonly known as measles. All of the following statements should be included in the informational handout EXCEPT
- A. Rubella can be spread by coughing and sneezing.'
- B. The incubation period for rubella is 3-7 days.'
- C. Signs and symptoms include high fever, runny nose, and cough.'
- D. Rubella can be spread by skin-to-skin contact.'
Correct Answer: B
Rationale: Rubella’s incubation period is 12-23 days, not 3-7 days. It spreads via respiratory droplets (coughing/sneezing), not skin-to-skin. Symptoms include fever and rash, but runny nose and cough are more typical of measles.
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The nurse is assessing the reflexes of a full-term newborn infant. Which of the following is true regarding newborn reflexes?
- A. The Babinski reflex disappears after 1 year of age.
- B. Complete fencing response disappears by 2 months.
- C. The stepping or 'walking' reflex is present until 3-4 months.
- D. The Moro reflex is present at birth and disappears by 6 months.
Correct Answer: D
Rationale: The Moro reflex, present at birth, typically disappears by 6 months. Babinski persists until ~2 years, fencing (tonic neck) until 4-6 months, and stepping until 1-2 months.
Twenty micrograms (g) are equal to how many milligrams? Record your answer using a decimal number.
Correct Answer: 0.02
Rationale: 1 mg = 1,000 g, so 20 /1,000 = 0.02 mg.
The nurse is conducting an aphasia assessment of a client who has suffered a stroke. Which of the following observations should the nurse include in the assessment? Select all that apply.
- A. Spontaneous speech.
- B. Comprehension of the spoken and written word.
- C. Ability to name objects.
- D. Ability to describe objects.
- E. Ability to write.
- F. Ability to recall four named items after five minutes.
Correct Answer: A,B,C,D,E
Rationale: Aphasia assessment post-stroke includes evaluating spontaneous speech (A), comprehension (B), naming objects (C), describing objects (D), and writing (E). Memory recall (F) is not specific to aphasia.
A woman has undergone a mastectomy of her right breast and has been brought to the recovery unit. The nurse explains that the client should
- A. keep her right arm elevated on a pillow.
- B. keep her right arm elevated above her head.
- C. keep her right arm level with the heart.
- D. keep her right arm slightly lower than her heart.
Correct Answer: A
Rationale: Elevating the arm on a pillow reduces lymphedema risk post-mastectomy by promoting lymphatic drainage.
The doctor has ordered Percocet (oxycodone) for a client following abdominal surgery. The primary objective of nursing care for the client receiving an opiate analgesic is:
- A. Preventing addiction
- B. Alleviating pain
- C. Facilitating mobility
- D. Preventing nausea
Correct Answer: B
Rationale: The primary goal of opiate analgesics like Percocet is to alleviate pain, improving comfort and recovery post-surgery.