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The nurse caring for a child diagnosed with rubeola (measles) notes that the primary health care provider has documented the presence of Koplik's spots. On the basis of this documentation, which observation is expected?
- A. Pinpoint petechiae noted on both legs
- B. Whitish vesicles located across the chest
- C. Petechiae spots that are reddish and pinpoint on the soft palate
- D. Small, blue-white spots with a red base found on the buccal mucosa
Correct Answer: D
Rationale: In rubeola (measles), Koplik's spots appear approximately 2 days before the appearance of the rash. These are small, blue-white spots with a red base that are found on the buccal mucosa. The spots last approximately 3 days, after which time they slough off. Based on this information, the remaining options are all incorrect.
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The nurse assessing the level of consciousness of a child with a head injury documents that the child is obtunded. On the basis of this documentation, which observation did the nurse note?
- A. The child is unable to think clearly and rapidly.
- B. The child is unable to recognize place or person.
- C. The child always requires considerable stimulation for arousal.
- D. The child has limited interaction with the environment unless aroused.
Correct Answer: D
Rationale: If the child is obtunded, the child sleeps unless aroused and, when aroused, has limited interaction with the environment. The remaining options describe confusion, disorientation, and stupor.
A client who has been receiving long-term diuretic therapy is admitted to the hospital with a diagnosis of dehydration. The nurse should assess for which sign that correlates with this fluid imbalance?
- A. Decreased pulse
- B. Bibasilar crackles
- C. Increased blood pressure
- D. Increased urinary specific gravity
Correct Answer: D
Rationale: Assessment findings with fluid volume deficit are increased pulse and respirations, weight loss, poor skin turgor, dry mucous membranes, decreased urine output, concentrated urine with increased specific gravity, increased hematocrit, and altered level of consciousness. The assessment findings in the remaining options are not associated with dehydration.
The nurse prepares to administer a continuous intravenous (IV) infusion through a peripheral IV to a dehydrated client. Which priority assessment should the nurse obtain before initiating the IV infusion?
- A. Daily body weight
- B. Serum electrolytes
- C. Intake and output records
- D. Identifying the client's dominant side
Correct Answer: A
Rationale: The nurse obtains the client's baseline body weight as a priority before beginning the IV infusion because body weight is a sensitive and specific indicator of fluid volume status when body weights are compared on a daily basis. This means that as a client receives or accumulates fluid, body weight quickly and proportionately increases and vice versa. The remaining options may also be reasonable assessments to complete before initiating an IV infusion. However, intake, output, and serum electrolytes are potentially affected by more confounding factors; thus, they are less specific and sensitive to fluctuations in body fluid. Determining the client's dominant side assists in deciding a site for inserting the initial IV catheter, but it provides no information about fluid volume status.
A client is scheduled for an arteriogram using a radiopaque dye. What is the most important information the nurse should determine before the procedure to assure the client's safety?
- A. Vital signs
- B. Intake and output
- C. Height and weight
- D. Allergy to iodine or shellfish
Correct Answer: D
Rationale: Allergy to iodine or seafood is associated with allergy to the radiopaque dye that is used for medical imaging examinations. Informed consent is necessary because an arteriogram requires the injection of a radiopaque dye into the blood vessel. Although the remaining options are components of the preprocedure assessment, the risks of allergic reaction and possible anaphylaxis are the most critical to the client's safety.
The nurse is obtaining a history from a client who was admitted to the hospital with a thrombotic stroke. What are the most likely signs/symptoms the client experienced before the stroke occurred? Select all that apply.
- A. Temporary aphasia
- B. Throbbing headaches
- C. Transient hemiplegia
- D. Paresthesias of the hands and feet
- E. Unexplained loss of consciousness
Correct Answer: A,C,D
Rationale: Cerebral thrombosis does not occur suddenly. During the few hours or days before a thrombotic stroke, the client may experience a transient loss of speech (aphasia), hemiplegia, or paresthesias on one side of the body. Other signs and symptoms of thrombotic stroke vary, but they may include dizziness, cognitive changes, or seizures. Headache is rare, and a loss of consciousness is not likely to occur.