Nokea
The nurse is concerned that a patient is developing a complicated soft tissue bacterial infection. Which assessment finding is most indicative of this condition?
- A. Pain
- B. Fever
- C. Tachycardia
- D. Low blood pressure
Correct Answer: D
Rationale: Low blood pressure suggests systemic involvement (e.g., sepsis) in a complicated infection, beyond localized symptoms like pain or fever.
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Which of the following statements are correct regarding glomus tumours?
- A. These tumours rarely affect the nail beds
- B. They are extremely painful
- C. They are usually malignant
- D. A glomus body is found in the epidermis
Correct Answer: B
Rationale: Glomus tumors are extremely painful and arise from the glomus body located in the dermis.
Which recommendation should the nurse suggest to an elderly client who lives alone when discussing normal developmental changes of the olfactory organs?
- A. Suggest installing multiple smoke alarms in the home.
- B. Recommend using a night light in the hallway and bathroom.
- C. Discuss keeping a high-humidity atmosphere in the bedroom.
- D. Encourage the client to smell food prior to eating it.
Correct Answer: A
Rationale: Decreased olfactory function with aging impairs smoke detection; multiple smoke alarms enhance safety for an elderly client living alone.
In a client with human immunodeficiency virus (HIV), the nurse should assess for which complications that might be present?
- A. Kaposi neoplasms of the external surfaces of the eyelid, cotton-wool spots around the optic nerve, and cytomegalovirus (CMV) retinitis
- B. Retinitis pigmentosa with retinal atrophy
- C. Exudative macular degeneration
- D. All of the above
Correct Answer: A
Rationale: HIV-related eye complications include Kaposi neoplasms, cotton-wool spots, and CMV retinitis due to immune suppression. Retinitis pigmentosa and exudative macular degeneration are unrelated to HIV.
A child has been in the burn unit for 13 days. Which nursing assessment indicates that a priority goal has been met?
- A. Decreased albumen over 5 days
- B. Intake equals output for 24 hours
- C. Participates in dressing changes
- D. Weight gain of 0.5 kg in 1 week
Correct Answer: D
Rationale: Nutrition is an important problem for the child with burns, as the child is hypermetabolic and needs a high-calorie, high-protein diet. Children are generally weighed twice a week in the burn center. A weight gain shows that nutritional needs are being met.
The client is prescribed methotrexate for a diagnosis of psoriasis. Which data should the nurse monitor?
- A. The glomerular filtration rate.
- B. The blood urea nitrogen (BUN) and creatinine levels.
- C. The complete blood count (CBC).
- D. The iron-binding capacity.
Correct Answer: C
Rationale: Methotrexate causes hematopoietic depression (leukopenia, thrombocytopenia, anemia), so CBC monitoring is essential. It's not nephrotoxic, so GFR and BUN/creatinine aren't priorities, nor is iron-binding capacity affected.