Nokea
Nurse is caring for client who presents with linear clusters of fluid-containing vesicles with some crusting. Which should nurse suspect?
- A. Allergic reaction
- B. Ringworm
- C. Systemic lupus erythematosus
- D. Herpes zoster
Correct Answer: D
Rationale: The correct answer is D: Herpes zoster. The description of linear clusters of fluid-containing vesicles with some crusting is characteristic of herpes zoster, also known as shingles. This condition is caused by the reactivation of the varicella-zoster virus, which initially causes chickenpox. The linear distribution along a dermatome is a key feature of herpes zoster. Allergic reaction (A) typically presents with generalized rash and itching, not linear clusters of vesicles. Ringworm (B) presents as circular, scaly lesions, not linear clusters of vesicles. Systemic lupus erythematosus (C) is an autoimmune disease that presents with a variety of symptoms, but not linear clusters of vesicles.
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Nurse reviewing nutrition guidelines with parents of 11 yo. Which parent statement should indicate to nurse that they understand guidelines for school-age children?
- A. She wants to eat as much as us, but we're afraid she'll be overweight.
- B. She skips lunch sometimes but we figure it's okay as long as she has healthy breakfast & dinner.
- C. We limit fast food restaurant meals to 3x/week now
- D. We reward her school achievements with point system instead of pizza or ice cream
Correct Answer: D
Rationale: The correct answer is D because it demonstrates understanding of the guidelines by promoting non-food rewards for school achievements, which helps instill healthy habits and a positive relationship with food. This approach encourages the child to associate success with non-food rewards, fostering a healthy attitude towards food and eating habits. Choices A, B, and C focus on the child's weight, meal skipping, and fast food consumption, which are not aligned with the guidelines for school-age children. These choices may promote unhealthy eating behaviors or weight concerns.
Nurse educator presenting on basic first aid for new home health nurses. She evaluates teaching as effective when a new nurse states that a client who has heat stroke will have which of the following?
- A. Hypotension
- B. Bradycardia
- C. Clammy skin
- D. Bradypnea
Correct Answer: A
Rationale: The correct answer is A: Hypotension. Heat stroke leads to severe dehydration and vasodilation, causing a drop in blood pressure (hypotension). Bradycardia (B), clammy skin (C), and bradypnea (D) are not characteristic of heat stroke. Bradycardia is a slow heart rate, while heat stroke typically causes tachycardia. Clammy skin is more indicative of shock or hypoglycemia, not heat stroke. Bradypnea is slow breathing, but heat stroke usually leads to rapid, shallow breathing. Therefore, hypotension is the most appropriate choice as it aligns with the physiological response to heat stroke.
A nurse is preparing a care plan for a patient who is immobile. Which psychosocial aspect will the nurse consider?
- A. Loss of bone mass
- B. Loss of strength
- C. Loss of weight
- D. Loss of hope
Correct Answer: D
Rationale: The correct answer is D: Loss of hope. When a patient is immobile, they may experience feelings of hopelessness, leading to negative psychosocial impacts. The nurse must address this aspect in the care plan to promote the patient's mental well-being. Loss of bone mass (A), loss of strength (B), and loss of weight (C) are physical aspects related to immobility, not psychosocial. These factors are important but do not directly address the patient's emotional state. It is crucial for the nurse to focus on the psychosocial well-being of the patient to provide holistic care.
Nurse collecting hx & physical exam data from middle adult. Nurse should expect to find decreases in which physiologic functions? (Select all that apply.)
- A. Metabolism
- B. Ability to hear low-pitched sounds
- C. Gastric secretion
- D. Far vision
- E. Glomerular filtration
Correct Answer: A,C,E
Rationale: The correct answers are A, C, and E. As individuals age, metabolism decreases due to changes in muscle mass and activity levels. Gastric secretion decreases, leading to decreased absorption of certain nutrients. Glomerular filtration rate decreases with age, affecting kidney function. Choice B is incorrect as hearing high-pitched sounds is more commonly affected with age. Choice D is incorrect as near vision is usually affected, not far vision.
A nurse tells a client that she will call the surgeon about his request. The surgeon prescribes a full liquid diet. Which level of critical thinking did the nurse use?
- A. Basic
- B. Commitment
- C. Complex
- D. Integrity
Correct Answer: A
Rationale: The correct answer is A: Basic. The nurse's action of informing the surgeon about the client's request and following the prescribed full liquid diet shows a basic level of critical thinking. This decision involves understanding and following prescribed protocols without much analysis or interpretation. The other choices are incorrect because: B: Commitment would involve making a commitment to a course of action, C: Complex would involve analyzing and synthesizing information from various sources, and D: Integrity would involve adherence to ethical principles.