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What can you expect from Marianne, who is currently at the ONSET stage of fever?
- A. Hot, flushed skin
- B. Increase thirst
- C. Convulsion
- D. Pale,cold skin
Correct Answer: D
Rationale: Fever's onset (chill phase) features vasoconstriction e.g., pale, cold skin as the body raises its setpoint. Hot, flushed skin (flush phase), thirst (later), or convulsions (hyperpyrexia) follow. Nurses expect this initial response e.g., shivering in Marianne, guiding warming measures, per fever physiology.
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What equipment would be necessary to complete an evaluation of cranial nerves 9 and 10 during a physical assessment?
- A. A cotton ball
- B. A penlight
- C. An ophthalmoscope
- D. A tongue depressor and flashlight
Correct Answer: D
Rationale: Cranial nerves 9 and 10 (glossopharyngeal and vagus) are assessed with a gag reflex, requiring a tongue depressor and light.
During a physical assessment, a client was diagnosed with increased temperature due to an increased basal metabolic rate (BMR). Which hormonal imbalances may the client have? Select all that apply.
- A. Cortisol
- B. Thyroid
- C. Estrogen
- D. Testosterone
Correct Answer: B
Rationale: Increased BMR with elevated temperature suggests thyroid (B) excess (hyperthyroidism), boosting metabolism. Cortisol (A) affects stress, not BMR primarily. Estrogen (C) and testosterone (D) influence other systems. B is correct. Rationale: Thyroid hormones (T3, T4) directly raise BMR and heat, a classic endocrine imbalance, per physiology, unlike other hormones with indirect effects.
The parents of a healthy 6-year-old ask the nurse for advice about preventing obesity in their child. Which response reflects health promotion?
- A. Limit screen time and encourage outdoor play.'
- B. Weigh your child monthly to monitor for weight gain.'
- C. Give your child a multivitamin daily to prevent obesity.'
- D. Have your child's cholesterol checked annually.'
Correct Answer: A
Rationale: For a healthy 6-year-old, health promotion prevents obesity by fostering active habits limiting screen time and encouraging outdoor play boosts physical activity, burning calories and building muscle, key to avoiding weight gain at this age. Evidence links sedentary screen hours to childhood obesity; play counters it, aligning with nursing's focus on lifestyle over surveillance. Monthly weighing is secondary, tracking not preventing, and may stress the child. Multivitamins don't prevent obesity caloric balance does while annual cholesterol checks detect, not avert, issues. The nurse's reply promotes wellness through fun, practical steps like biking or tag tailored to a child's energy, ensuring long-term health without medicalizing a well kid, a cornerstone of pediatric nursing's preventive approach.
Which of the following statement is TRUE about patient safety?
- A. Only about medication
- B. Prevents harm in care
- C. Not a nursing concern
- D. All of the above
Correct Answer: B
Rationale: Patient safety prevents harm in care (B), per standards e.g., fall prevention. Not just meds (A), is nursing concern (C), not all (D) broad focus. B truly defines safety's aim, making it correct.
Client has undergone Upper GI and Lower GI series. Which type of health assessment framework is used in this situation?
- A. Functional health framework
- B. Head to toe framework
- C. Body system framework
- D. Cephalocaudal framework
Correct Answer: C
Rationale: Upper and Lower GI series use a body system framework (C), targeting digestive system, per assessment types. Functional (A) assesses ADLs, head-to-toe (B) and cephalocaudal (D) are physical sweeps. C fits organ focus, making it correct.