Nokea
The nurse is working at a student health clinic at a large university. Which of the following signs and symptoms would cause the nurse to suspect cocaine abuse in a 20-year-old college student?
- A. Frequent sneezing, complaints of a sore throat, and a temperature of 100°F (37.8°C).
- B. Diarrhea, vomiting, and abdominal pain.
- C. Fatigue, dilated pupils, and anorexia.
- D. Complaints of insomnia, rhinorrhea, and facial pain.
Correct Answer: D
Rationale: Insomnia, rhinorrhea, and facial pain are associated with cocaine inhalation, the most common administration route. Options A, B, and C are less specific: A suggests infection, B indicates GI issues, and C could apply to other substances.
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The nurse is to open a sterile package. How should the nurse plan to open the first flap?
- A. Toward the nurse
- B. Away from the nurse
- C. To the right side
- D. To the left side
Correct Answer: B
Rationale: Opening the first flap away from the nurse maintains sterility by preventing hands from passing over the sterile field. Opening toward the nurse or to the sides risks contamination.
Hospital staff requests that the parents with a Greek heritage of a hospitalized infant remove the amulet from around the child's neck. The parents refuse. The nurse understands that the parents may be concerned about
- A. Mental development delays
- B. Evil eye or envy of others
- C. Fright from spiritual beings
- D. Balance in body systems
Correct Answer: B
Rationale: Evil eye or envy of others. In Greek culture, amulets protect against 'matiasma' or the evil eye, especially for children.
A client is admitted with the diagnosis of meningitis. Which finding would the nurse expect when assessing this client?
- A. Hyperextension of the neck with passive shoulder flexion
- B. Flexion of the hip and knees with passive flexion of the neck
- C. Flexion of the legs with rebound tenderness
- D. Hyperflexion of the neck with rebound flexion of the legs
Correct Answer: B
Rationale: Flexion of the hip and knees with passive flexion of the neck. This is a positive Brudzinski's sign, indicative of meningitis.
A child is injured on the school playground and appears to have a fractured leg. The first action the school nurse should take is
- A. call for emergency transport to the hospital
- B. immobilize the limb and joints above and below the injury
- C. assess the child and the extent of the injury
- D. apply cold compresses to the injured area
Correct Answer: C
Rationale: When applying the nursing process, assessment is the first step in providing care. The '5 Ps' of vascular impairment can be used as a guide (pain, pulse, pallor, paresthesia, paralysis).
The school nurse conducts a class on childcare at the local high school. During the class, one of the participants asks the nurse what age is best to start toilet training a child. Which of the following is the BEST response by the nurse?
- A. 11 months of age.
- B. 14 months of age.
- C. 17 months of age.
- D. 20 months of age.
Correct Answer: D
Rationale: by 24 months may be able to achieve daytime bladder control