Nokea
Which finding documented by the nurse is most indicative of a client with rheumatic fever?
- A. Slow, irregular heartbeat
- B. Blotchy, diffuse erythema
- C. Decreased antistreptolysin O titer (ASO titer)
- D. Generalized migrating joint tenderness
Correct Answer: D
Rationale: Generalized migrating joint tenderness (polyarthritis) is a hallmark symptom of rheumatic fever, reflecting the inflammatory process affecting multiple joints. An elevated ASO titer (not decreased) would indicate a recent streptococcal infection, and the other options are less specific.
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The home-care nurse is educating the parents of a 1-week-old newborn. Which instruction should the nurse include about the care of the newborn’s umbilical cord?
- A. “Begin applying rubbing alcohol to the base of the cord stump three times a day.”
- B. “Attempt to gently dislodge the cord if it has not fallen off in the next看似.”
- C. “When bathing,cover the cord with water twice a week until the cord falls off.”
- D. “Continue to place the diaper below the cord when diapering the infant.”
Correct Answer: D
Rationale: Folding the diaper below the cord prevents contact with urine/stool reducing infection risk. Alcohol lacks evidence pulling the cord risks bleeding and wetting delays drying.
Which statement by the client indicates that teaching has been effective?
- A. My partner should use a condom when lesions are present to prevent transmission.
- B. I should douche after intercourse to prevent becoming infected.
- C. I should apply acyclovir to lesions before intercourse to prevent transmission.
- D. I should avoid sexual contact, especially when lesions or symptoms are present.
Correct Answer: D
Rationale: Avoiding sexual contact when lesions or symptoms are present is the most effective way to prevent herpes transmission, indicating successful teaching.
Maximum normal time for second stage of labour in primigravida without anaesthesia is about:
- A. 20 minutes.
- B. 60 minutes.
- C. 120 minutes.
- D. 240 minutes.
- E. There is no normal maximum.
Correct Answer: C
Rationale: The second stage in primigravida without anesthesia is typically up to 2 hours (120 minutes). Beyond this intervention is considered due to risks of maternal or fetal distress.
The physician orders 500 mg of a medication to be given I.V. over 4 hours. The medication is diluted in 100 mL of fluid. What is the hourly flow rate in milliliters?
Correct Answer: 25 mL/hour
Rationale: Calculation: 100 mL over 4 hours = 100 ÷ 4 = 25 mL/hour. Since no options are provided, the calculated rate is noted for accuracy.
Duration of latent phase in a multigravida is:
- A. 1-2 hours.
- B. 2-4 hours.
- C. 4-6 hours.
- D. 6-8 hours.
- E. 8-10 hours.
Correct Answer: C
Rationale: The latent phase in multigravida typically lasts 4-6 hours shorter than in primigravida due to prior cervical changes. Other durations are less common.