Nokea
Which of the following findings is a clinical manifestation associated with this diagnosis?
- A. Tachypnea
- B. Tremors
- C. Increased appetite
- D. Bradycardia
Correct Answer: A
Rationale: The correct answer is A: Tachypnea. Tachypnea refers to rapid breathing, which is a common clinical manifestation associated with various medical conditions, including respiratory distress. In this particular diagnosis, tachypnea may indicate underlying respiratory issues or distress. Tremors (B) and increased appetite (C) are not typically associated with this diagnosis. Bradycardia (D), which is a slow heart rate, is also not a common clinical manifestation in this context.
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Which of the following findings should the nurse identify as a manifestation of scabies?
- A. Scaly lesions on the inner thighs
- B. Rash with red macular lesions on the scalp
- C. Bull's eye edematous area on the groin
- D. Maculopapular skin burrows on the hand
Correct Answer: D
Rationale: The correct answer is D: Maculopapular skin burrows on the hand. Scabies is caused by the Sarcoptes scabiei mite, which burrows into the skin, causing characteristic burrows that appear as thin, wavy, and slightly raised grayish-white or skin-colored lines. These burrows are commonly found on the hands, fingers, wrists, and interdigital spaces. Scaly lesions on the inner thighs (A) are more indicative of fungal infections. Rash with red macular lesions on the scalp (B) is more suggestive of conditions like seborrheic dermatitis or psoriasis. A bull's eye edematous area on the groin (C) is more characteristic of Lyme disease. In summary, the presence of maculopapular skin burrows on the hand is a key manifestation of scabies, differentiating it from the other options provided.
Which of the following actions should the nurse take first?
- A. Observe the child's throat with a flashlight.
- B. Give the child small sips of water.
- C. Administer an analgesic.
- D. Offer the child an ice collar.
Correct Answer: A
Rationale: The correct answer is A: Observe the child's throat with a flashlight. This is the first action the nurse should take as it helps assess for any signs of inflammation, infection, or obstruction in the throat, which could be causing the child's symptoms. By observing the throat, the nurse can gather important information to guide further interventions.
Choice B: Giving the child small sips of water can be important but should come after assessing the throat to ensure it is safe to swallow. Choice C: Administering an analgesic should be based on the assessment findings, not the first action. Choice D: Offering an ice collar is not indicated until the cause of the symptoms is identified.
Which of the following immunizations should the nurse plan to administer?
- A. Measles, mumps, and rubella (MMR)
- B. Varicella (VAR)
- C. Rotavirus (RV)
- D. Herpes zoster
- E. Human papillomavirus (HPV4)
Correct Answer: A,B
Rationale: The correct answer is A (MMR) and B (VAR). These immunizations are recommended for certain age groups to prevent measles, mumps, rubella, and varicella. MMR provides protection against three viral infections, while VAR protects against chickenpox. These vaccinations are part of the routine childhood immunization schedule to prevent the spread of these contagious diseases. Rotavirus (C) is given to infants to protect against a common cause of severe diarrhea, while Herpes zoster (D) and Human papillomavirus (E) are not typically administered by nurses in routine practice.
Specify what condition the client is most likely experiencing.
- A. Pyloric stenosis
- C. Congestive heart failure
- D. Respiratory syncytial virus bronchiolitis
Correct Answer: C
Rationale: The correct answer is C: Congestive heart failure. The client is most likely experiencing Congestive heart failure due to presenting symptoms such as dyspnea, fatigue, edema, and possibly crackles on lung auscultation. These symptoms are indicative of fluid accumulation in the lungs and peripheral tissues, common in congestive heart failure. Pyloric stenosis (A) is a gastrointestinal condition, not related to the symptoms described. Respiratory syncytial virus bronchiolitis (D) typically presents with respiratory distress in infants. The other choices are omitted as they are not relevant to the symptoms described.
Which of the following reactions is an age-appropriate response to death?
- A. The child views the sibling's death as permanent.
- B. The child is curious about what happened to the sibling's body.
- C. The child can give a logical explanation for the sibling's death.
- D. The child feels responsible for the sibling's death.
Correct Answer: B
Rationale: The correct answer is B because it reflects a common and age-appropriate response to death in children. Curiosity about what happened to the body is natural as children try to make sense of the concept of death. It shows a child's attempt to understand the physical aspect of death without fully grasping its emotional implications. Choices A, C, and D are incorrect. A is incorrect because children often struggle with understanding death as permanent. C is incorrect because logical explanations for death usually come later in development. D is incorrect because children typically do not feel responsible for a sibling's death at a young age.