Nokea
The mother of the child diagnosed with Kawasaki disease asks the nurse about the disorder. On which description of this disorder should the nurse base the response to the mother?
- A. It is an acquired cell-mediated immunodeficiency disorder.
- B. It is a chronic multisystem autoimmune disease characterized by the inflammation of connective tissue.
- C. It is also called mucocutaneous lymph node syndrome and is a febrile generalized vasculitis of unknown etiology.
- D. It is an inflammatory autoimmune disease that affects the connective tissue of the heart, joints, and subcutaneous tissues.
Correct Answer: C
Rationale: Kawasaki disease, also called mucocutaneous lymph node syndrome, is a febrile generalized vasculitis of unknown etiology. Option 1 describes human immunodeficiency virus infection. Option 2 describes systemic lupus erythematosus. Option 4 describes rheumatic fever.
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A client in a cardiac rehabilitation program states that he would like to make sure he is eating the right foods to ensure adequate endurance on the treadmill. Which of the following nutrients is most helpful for promoting endurance during sustained activity?
- A. Protein.
- B. Carbohydrate.
- C. Fat.
- D. Water.
Correct Answer: B
Rationale: Carbohydrates are the primary energy source for sustained physical activity, providing glycogen stores for endurance.
A client admitted in an acute psychotic state says that she hears terrible voices in the head and thinks her neighbor is out to get her. Which of the following is the nurse's best response?
- A. What has your neighbor been doing that bothers you?'
- B. How long have you been hearing these terrible voices?'
- C. I won't let your neighbor visit, so you'll be safe.'
- D. What exactly are these terrible voices saying to you?'
Correct Answer: D
Rationale: Asking about the content of the voices helps assess the nature of the hallucinations and potential risks, guiding therapeutic intervention.
When cleaning the skin around an incision and drain site, which of the following procedures should the nurse follow?
- A. Clean the incision and drain site separately.
- B. Clean from the incision to the drain site.
- C. Clean from the drain site to the incision.
- D. Clean the incision and drain site simultaneously.
Correct Answer: A
Rationale: Cleaning separately prevents cross-contamination between the incision and drain site, reducing infection risk.
The doctor orders a midstream urine specimen for your client who is an alert, oriented and ambulatory female client. What element should you include in your instructions to this client on the proper manner to collect this specimen?
- A. The need to cleanse the perineal area with circular wipes.
- B. The need to cleanse the perineal area from the 'dirtiest' to the 'cleanest'.
- C. The need to use a new antiseptic wipe for each wipe from the inner to the outer labia.
- D. The need to use a new antiseptic wipe for each wipe from the outer to the inner labia.
Correct Answer: C
Rationale: For a midstream urine specimen, the perineal area should be cleansed from front to back (inner to outer labia) using a new antiseptic wipe for each stroke to prevent contamination.
A client with schizophrenia is prescribed risperidone (Risperdal). The nurse should teach the client to report which side effect immediately?
- A. Weight gain
- B. Dry mouth
- C. Tremors
- D. Insomnia
Correct Answer: C
Rationale: Tremors may indicate extrapyramidal side effects, such as parkinsonism, which require prompt reporting to adjust the dose or add an antiparkinsonian medication.