Nokea
On assessment of the client diagnosed with stage III Lyme disease, which clinical manifestation should the nurse expect to note?
- A. Palpitations
- B. A cardiac dysrhythmia
- C. A generalized skin rash
- D. Enlarged and inflamed joints
Correct Answer: D
Rationale: Stage III Lyme disease develops within a month to several months after initial infection. It is characterized by arthritic symptoms such as arthralgia and enlarged or inflamed joints, which can persist for several years after the initial infection. A rash occurs during stage I, and cardiac and neurological dysfunction occur during stage II.
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A child experienced a basilar skull fracture that resulted in the presence of Battle's sign. Which should the nurse expect to observe in the child?
- A. Bruising behind the ear
- B. The presence of epistaxis
- C. A bruised periorbital area
- D. An edematous periorbital area
Correct Answer: A
Rationale: The most serious type of skull fracture is a basilar skull fracture. Two classic findings associated with this type of skull fracture are Battle's sign and raccoon eyes. Battle's sign is the presence of bruising or ecchymosis behind the ear caused by a leaking of blood into the mastoid sinuses. Raccoon eyes occur as a result of blood leaking into the frontal sinus and causing an edematous and bruised periorbital area.
When assessing a child which finding would indicate the presence of Kernig's sign?
- A. Calf pain when the foot is dorsiflexed
- B. Pain when the chin is pulled down to the chest
- C. The inability of the child to extend the legs fully when lying supine
- D. The flexion of the hips when the neck is flexed from a lying position
Correct Answer: C
Rationale: Kernig's sign is the inability of the child to extend the legs fully when lying supine. Brudzinski's sign is flexion of the hips when the neck is flexed from a supine position. Both of these signs are frequently present in clients with bacterial meningitis. Nuchal rigidity is also present with bacterial meningitis, and it occurs when pain prevents the child from touching the chin to the chest. Homans' sign is elicited when pain occurs in the calf region when the foot is dorsiflexed.
Which aspect should the nurse focus on when assessing a client for the vegetative signs of depression? Select all that apply.
- A. Weight
- B. Appetite
- C. Sleep patterns
- D. Suicidal ideations
- E. Psychomotor activity
- F. Rational decision making
Correct Answer: A,B,C,E
Rationale: The vegetative signs of depression are changes in physiological functioning that occur during depression. These include changes in appetite, weight, sleep patterns, and psychomotor activity. The remaining options represent psychological assessment categories.
An adult client seeks treatment in an ambulatory care clinic for reports of a left earache, nausea, and a full feeling in the left ear. The client has an elevated temperature. Which assessment question should the nurse ask first?
- A. Do you have a history of a recent brain abscess?
- B. Do you have a chronic hearing problem in the left ear?
- C. Do you successfully obtain pain relief with acetaminophen?
- D. Do you have a history of a recent upper respiratory infection (URI)?
Correct Answer: D
Rationale: Otitis media in the adult is typically one-sided and presents as an acute process with earache; nausea; and possible vomiting, fever, and fullness in the ear. The client may report diminished hearing in that ear during the acute process. The nurse takes a client history first, assessing whether the client has had a recent URI. It is unnecessary to question the client about a brain abscess. The nurse may ask the client if anything relieves the pain, but ear infection pain is usually not relieved until antibiotic therapy is initiated.
The nurse is preparing a woman in labor for an amniotomy. Which priority data should the nurse assess before the procedure?
- A. Fetal heart rate
- B. Maternal heart rate
- C. Fetal scalp sampling
- D. Maternal blood pressure
Correct Answer: A
Rationale: Fetal well-being must be confirmed before and after amniotomy. Fetal heart rate should be checked by Doppler or with the application of the external fetal monitor. Although maternal vital signs may be assessed, fetal heart rate is the priority. A fetal scalp sampling cannot be done when the membranes are intact.