Nokea
The nurse is assessing a client who has herpes zoster. Which question will allow the nurse to gather further information about this condition?
- A. Has everyone at home already had varicella?
- B. Have the antifungal creams been effective?
- C. Do you have any dry patches on your feet and hands?
- D. Do your family members share combs and brushes?
Correct Answer: A
Rationale: Asking if everyone at home has had varicella helps determine the risk of transmission of the varicella-zoster virus, which causes herpes zoster, to non-immune individuals, informing isolation precautions.
You may also like to solve these questions
A client with obstructive sleep apnea (OSA) calls the clinic to report difficulty wearing the continuous positive air pressure (CPAP) mask because it is uncomfortable. The client asks the nurse for an alternative way to manage sleep apnea. Which recommendation should the nurse provide?
- A. Begin a weight loss program.
- B. Drink 1 to 2 glasses of wine at bedtime.
- C. Take sedatives prior to sleep.
- D. Sleep with the head of the bed flat.
Correct Answer: A
Rationale: Weight loss can reduce fat deposits around the neck and throat, improving airflow and decreasing the severity of OSA, making it an effective alternative or complementary strategy to CPAP.
A client admitted to the emergency department with an acute exacerbation of peptic ulcer disease is vomiting and describing epigastric pain and nausea. After obtaining vital sign measurements, which prescription should the nurse implement first?
- A. Insert a nasogastric tube (NGT) and attach to low intermittent suction.
- B. Give a prescribed analgesic for temperature above 101°F (38.3° C).
- C. Place an indwelling urinary catheter and attach a bedside drainage unit.
- D. Send the client to x-ray for a flat plate of the abdomen.
Correct Answer: A
Rationale: Inserting an NGT with low intermittent suction decompresses the stomach, removes gastric contents, and relieves vomiting and pain, addressing the acute symptoms of peptic ulcer exacerbation first.
A client with sickle cell anemia develops a fever during the last hour of administration of a unit of packed red blood cells. When notifying the healthcare provider, which information should the nurse provide first using the SBAR (Situation, Background, Assessment, and Recommendation) communication process?
- A. Explain specific reason for urgent notification.
- B. Obtain a PRN prescription for acetaminophen for fever over 101° F (38.3° C).
- C. Preface the report by stating the client's name and admitting diagnosis.
- D. Communicate the pre-transfusion temperatures.
Correct Answer: C
Rationale: Per SBAR, starting with the client's name and diagnosis establishes identity and context, ensuring clear communication before detailing the situation, background, assessment, and recommendation.
The nurse calls the healthcare provider because a client diagnosed with an abdominal aortic aneurysm (AAA) is reporting of low back pain. Which additional information about the client would be important for the nurse to tell the healthcare provider?
- A. White blood cell count and pulse rate.
- B. Hematocrit and blood pressure.
- C. Calcium level and skin condition.
- D. Serum amylase and level of consciousness.
Correct Answer: B
Rationale: Hematocrit and blood pressure are critical for AAA, as low hematocrit may indicate rupture or bleeding, and high blood pressure can exacerbate the aneurysm, necessitating urgent reporting.
An older client who experienced a cerebrovascular accident (CVA) has difficulty with visual perception and eats only half of the food on the meal tray. The client's family expresses concern about the client's nutritional status. How should the nurse respond to the family's concern?
- A. Demonstrate the use of visual scanning during meals to the client and family.
- B. Explain that weight loss will be reversed after the acute phase of the stroke has ended.
- C. Suggest that the family bring foods from home that the client enjoys eating.
- D. Encourage the family to offer to feed the client when she does not eat her entire meal.
Correct Answer: A
Rationale: Teaching visual scanning compensates for visual perception deficits post-CVA, enabling the client to see all food on the tray, addressing the root cause of poor intake and improving nutrition.