Nokea
A patient presents with intensely pruritic, linear burrows on the web spaces of the hands and wrists. The patient reports a history of close contact with an individual diagnosed with a similar condition. Which of the following conditions is most likely responsible for this presentation?
- A. Scabies
- B. Pediculosis (lice infestation)
- C. Tinea corporis (ringworm)
- D. Contact dermatitis
Correct Answer: A
Rationale: The correct answer is A: Scabies. This presentation is classic for scabies infestation caused by the Sarcoptes scabiei mite. The intensely pruritic linear burrows are pathognomonic. Close contact with an individual with scabies increases the likelihood of transmission. The other choices, B: Pediculosis, C: Tinea corporis, and D: Contact dermatitis, do not typically present with linear burrows on the hands and wrists. Pediculosis presents with lice infestation, Tinea corporis with circular lesions, and contact dermatitis with erythema and edema.
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A postpartum client presents with severe abdominal pain, nausea, and vomiting. Which nursing action is most appropriate?
- A. Administering antiemetic medication as ordered
- B. Encouraging the client to drink clear fluids
- C. Assessing for signs of peritonitis or surgical abdomen
- D. Providing a heating pad to alleviate abdominal discomfort
Correct Answer: C
Rationale: In a postpartum client who presents with severe abdominal pain, nausea, and vomiting, it is crucial to assess for signs of peritonitis or surgical abdomen. These signs may include rebound tenderness, guarding, rigidity, and fever. Peritonitis is a serious condition that may require immediate surgical intervention. Administering antiemetic medication, encouraging clear fluids, or providing a heating pad may not address the underlying cause of the symptoms and delay appropriate treatment. Assessing for signs of peritonitis or surgical abdomen is crucial for prompt identification and management of the client's condition.
The Nurse asks Baste, who is being admitted in a district hospital with uncontrolled diabetes mellitus, about his employment status. She knows that _____.
- A. A person's compliance is affected by one's affected economic status
- B. Baste's employment will cause complication to his diabetes
- C. External variables have little effected on compliance
- D. Diabetes mellitus will affect his client's work condition
Correct Answer: A
Rationale: Rationale: A person's compliance with diabetes management can be influenced by economic status, as financial concerns can impact access to medications, healthy food, and healthcare. This can affect treatment adherence and overall health outcomes. Choice A is correct because addressing economic factors is important in promoting compliance. Choices B, C, and D are incorrect as they do not directly address the relationship between economic status and compliance with diabetes management.
A patient presents with a painful, vesicular rash following a linear pattern on the left forearm. The patient reports a history of gardening without gloves. Which of the following conditions is most likely responsible for this presentation?
- A. Allergic contact dermatitis
- B. Herpes simplex virus infection
- C. Scabies
- D. Poison ivy dermatitis
Correct Answer: B
Rationale: The correct answer is B: Herpes simplex virus infection. The presentation of a painful, vesicular rash following a linear pattern on the left forearm is characteristic of herpes simplex virus infection, specifically herpes zoster (shingles). The linear pattern is due to the virus following a specific nerve pathway. This is different from the other choices - A: Allergic contact dermatitis typically presents as a diffuse rash at the site of contact with an allergen, not a linear pattern. C: Scabies presents with burrows and papules, not vesicles in a linear pattern. D: Poison ivy dermatitis causes a diffuse rash, not a linear vesicular rash.
To promote drainage and reduce pressure from fluid, Nurse Selma nursing intervention is to have the child assume any of the following positions, EXCEPT _____.
- A. tilt head to side if sitting up.
- B. Lie on the affected area
- C. put the pillows behind the head
- D. lie on the non-affected ear.
Correct Answer: B
Rationale: The correct answer is B: Lie on the affected area. This position would hinder drainage and increase pressure on the affected area. A: Tilt head to the side if sitting up, is correct as it promotes drainage. C: Putting pillows behind the head can also aid drainage. D: Lying on the non-affected ear can help reduce pressure on the affected side.
The physician inserted a chest tube drainage to Mr. Alda in order to help re-expand the lungs. Which of the following should you prepare FIRST as a nurse in case of emergency when the tube is accidentally disconnected?
- A. sterile clamps
- B. Sterile dressing.
- C. Another chest tube
- D. A bottle of sterile water.
Correct Answer: A
Rationale: Correct Answer: A - sterile clamps
Rationale:
1. **Immediate action**: Sterile clamps are essential to clamp the chest tube to prevent air from entering the pleural space.
2. **Prevent lung collapse**: Clamping the tube will prevent lung collapse and maintain positive pressure in the pleural space.
3. **Buy time**: By clamping the tube, you buy time to properly reattach the tube or secure it with a new connection.
4. **Safety**: Sterile clamps are a quick and effective solution to prevent a potentially life-threatening situation.
Summary of other choices:
B: Sterile dressing - Not the first priority as the immediate concern is preventing air from entering the pleural space.
C: Another chest tube - Not necessary initially as clamping can buy time to reattach the disconnected tube.
D: A bottle of sterile water - Not needed for emergency management of a disconnected chest tube.