Nokea
When assessing a client, the nurse notes the typical skin rash seen with systemic lupus erythematosus. Which of the following descriptions correctly describes this rash?
- A. Small round or oval reddish brown macules scattered over the entire body
- B. Scattered clusters of macules, papules, and vesicles over the body
- C. Bright red appearance of the palmar surface of the hands
- D. Reddened butterfly shaped rash over the cheeks and nose
Correct Answer: D
Rationale: The appearance of small, round or oval reddish brown macules scattered over the entire body is characteristic of rubeola. The appearance of scattered clusters of macules, papules, and vesicles throughout the body is characteristic of chickenpox. Palmar redness is seen in clients with cirrhosis of the liver. The characteristic butterfly rash over the cheek and nose and into the scalp is seen with systemic lupus erythematosus.
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The nurse is trying to help a mother understand what is happening with her son who has recently been diagnosed with paranoid schizophrenia. At present, he is experiencing hallucinations and delusions of persecution and suffers from poor hygiene. The nurse can best help her understand her son's condition by which of the following statements?
- A. Sometimes these symptoms are caused by an overstimulation of a chemical called dopamine in the brain.'
- B. Has anyone in your family ever had schizophrenia?'
- C. If your son has a twin, he probably will eventually develop schizophrenia, too.'
- D. Some of his symptoms may be a result of his lack of a strong mother-child bonding relationship.'
Correct Answer: A
Rationale: The most plausible theory to date is that dopamine causes an overstimulation in the brain, which results in the psychotic symptoms.
A client with a history of a stroke is being discharged. The nurse should teach the client to:
- A. Avoid all physical activity
- B. Use assistive devices as needed
- C. Limit social interactions
- D. Eat a high-sodium diet
Correct Answer: B
Rationale: Assistive devices (e.g., cane, walker) promote safety and mobility post-stroke. Physical activity is encouraged, social interactions are beneficial, and sodium should be limited.
A 23-year-old college student seeks medical attention at the college infirmary for complaints of severe fatigue. Her skin is pale, and she reports exertional dyspnea. She is admitted to the hospital with possible aplastic anemia. Laboratory values reflect anemia, and the client is prepared for a bone marrow biopsy. She refuses to sign the biopsy consent and states, 'Can't you just get the doctor to give me a transfusion and let me go. This weekend begins spring break, and I have plans to go to Florida.' At this time the nurse's greatest concern is that:
- A. The client may contract an infection as a result of being exposed to large crowds at spring break
- B. The client does not grasp the full impact of her illness
- C. The client may require transfusion before leaving for spring break
- D. The causative agent be identified and treatment begun
Correct Answer: B
Rationale: The client could contract an infection, but at this point it is not the most pertinent issue. The client's statement indicates that she does not grasp the full impact of her illness. Further client education must be given, along with allowing her to express her feelings regarding her illness. The client may require a transfusion, but this is a temporary measure because the causative agent has not been identified. Her feelings regarding her illness must be addressed in order for care to continue. A bone marrow is done first to make a definitive diagnosis; then treatment may begin.
The nurse assists a client with advanced emphysema to the bathroom. The client becomes extremely short of breath while returning to bed. The nurse should:
- A. Increase his nasal O2 to 6 L/min
- B. Place him in a lateral Sims' position
- C. Encourage pursed-lip breathing
- D. Have him breathe into a paper bag
Correct Answer: C
Rationale: Pursed-lip breathing helps blow off CO2 and keep air passages open, reducing shortness of breath. Increasing O2 too high may remove the breathing stimulus, and the other options are not appropriate.
A camp nurse is applying sunscreen to a group of children enrolled in swim classes. Chemical sunscreens are most effective when applied:
- A. Just before sun exposure
- B. Five minutes before sun exposure
- C. 15 minutes before sun exposure
- D. 30 minutes before sun exposure
Correct Answer: D
Rationale: Chemical sunscreens require 30 minutes to absorb into the skin for optimal UV protection. Applying closer to exposure reduces effectiveness.