What are early signs of varicella disease?
- A. High fever over 101°F (38.3°C)
- B. General malaise
- C. Increased appetite
- D. Crusty sores
Correct Answer: B
Rationale: The correct early sign of varicella disease is general malaise. During the prodromal period, patients may experience low-grade fever, malaise, and anorexia. Increased appetite and crusty sores are not typically early signs of varicella. The appearance of lesions occurs later in the course of the disease.
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A 55-year-old client with symptoms of osteoarthritis asks which form of exercise would be most beneficial. What is the best response by the nurse?
- A. Walking.
- B. Running.
- C. Swimming.
- D. Weight lifting.
Correct Answer: C
Rationale: The correct answer is C: 'Swimming.' Swimming is a low-impact exercise that helps maintain joint mobility and reduce pain in clients with osteoarthritis. Unlike running or weight lifting, swimming is gentle on the joints, making it an ideal choice for individuals with osteoarthritis. Walking can be beneficial too, but swimming is often preferred due to its low-impact nature. Running and weight lifting may exacerbate joint pain and should be avoided by individuals with osteoarthritis.
The nurse is caring for a client with a suspected stroke. Which assessment finding is most indicative of a stroke?
- A. Chest pain
- B. Sudden confusion and difficulty speaking
- C. Gradual onset of weakness in the legs
- D. Nausea and vomiting
Correct Answer: B
Rationale: The correct answer is B: Sudden confusion and difficulty speaking. These are classic signs of a stroke, indicating a neurological deficit that requires urgent medical attention. Choices A, C, and D are less indicative of a stroke. Chest pain is more commonly associated with cardiac issues, gradual onset of weakness in the legs could be related to other conditions like peripheral neuropathy, and nausea/vomiting may suggest gastrointestinal problems rather than a stroke.
Which nursing intervention is most important for the nurse to implement when caring for an older client who is legally blind?
- A. Keep the room well-lit at all times.
- B. Speak to the client each time the nurse enters the room.
- C. Ensure the client wears glasses at all times.
- D. Provide written instructions in large print.
Correct Answer: B
Rationale: The correct answer is to speak to the client each time the nurse enters the room. This intervention is crucial for orienting and reassuring the client, promoting safety, and facilitating communication. Keeping the room well-lit (Choice A) can be helpful but is not as essential as direct verbal communication. Ensuring the client wears glasses (Choice C) may not be feasible or necessary for someone who is legally blind. Providing written instructions in large print (Choice D) is not effective for a client with visual impairments.
While planning care for a client with carpal tunnel syndrome, the nurse identifies a collaborative problem of pain. What is the etiology of this problem?
- A. Irritation of nerve endings
- B. Diminished blood flow
- C. Ischemic tissue changes
- D. Compression of a nerve
Correct Answer: D
Rationale: The correct answer is D: Compression of a nerve. In carpal tunnel syndrome, pain arises from the compression of the median nerve within the carpal tunnel. This compression leads to symptoms such as pain, numbness, and tingling in the hand and arm. Choices A, B, and C are incorrect because carpal tunnel syndrome pain is primarily caused by the physical compression of the nerve, rather than irritation of nerve endings, diminished blood flow, or ischemic tissue changes.
Parents of a 6-month-old child, who has just been diagnosed with iron deficiency anemia, ask why it was not diagnosed earlier. What would be the best response by the nurse?
- A. Are you sure your child has iron deficiency anemia?
- B. This happens when the maternal stores of iron are depleted at about 6 months.
- C. This anemia is caused by blood loss.
- D. The child may not have had it for a long time.
Correct Answer: B
Rationale: The best response by the nurse would be choice B: 'This happens when the maternal stores of iron are depleted at about 6 months.' Iron deficiency anemia becomes apparent at about 6 months of age in a full-term infant when the maternal stores of iron are depleted. Choice A is incorrect because it questions the diagnosis provided by the healthcare provider. Choice C is incorrect because iron deficiency anemia in infants is primarily due to insufficient iron intake rather than blood loss. Choice D is incorrect as iron deficiency anemia typically develops gradually due to inadequate iron intake.