Nokea
Which of the following signs and symptoms would a nurse expect when examining a 22-year-old female with secondary syphilis?
- A. chancre sore near the vagina
- B. no noticeable symptoms
- C. non-itchy rash on palms and soles of the feet
- D. skin tumors
Correct Answer: C
Rationale: Secondary syphilis presents with a non-itchy rash, often on the palms and soles. Chancres are primary syphilis, and skin tumors are tertiary syphilis.
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A 5-month-old infant is admitted to the ER with a temperature of 103.6°F and irritability. The mother states that the child has been listless for the past several hours and that he had a seizure on the way to the hospital. A lumbar puncture confirms a diagnosis of bacterial meningitis. The nurse should assess the infant for:
- A. Periorbital edema
- B. Tenseness of the anterior fontanel
- C. Positive Babinski reflex
- D. Negative scarf sign
Correct Answer: B
Rationale: Tenseness of the anterior fontanel indicates increased intracranial pressure, a critical finding in bacterial meningitis in infants.
A client scheduled for a carotid endarterectomy requires insertion of an intra-arterial blood pressure-monitoring device. The nurse plans to perform the Allen test. Which observation indicates patency of the ulnar artery?
- A. Blanching of the hand on compression and release of the ulnar artery
- B. Muscular twitching of the bicep muscle with use of a tourniquet at the wrist
- C. Hand turning pink after the nurse releases the pressure on the ulnar artery
- D. Flexion of the wrist when tapping the ulnar artery with a reflex hammer
Correct Answer: C
Rationale: The Allen test assesses collateral circulation. The hand turning pink after releasing ulnar artery pressure indicates patency, ensuring adequate blood flow if the radial artery is cannulated.
The physician has ordered cortisporin ear drops for a 2-year-old. To administer the ear drops, the nurse should:
- A. Pull the ear down and back
- B. Pull the ear straight out
- C. Pull the ear up and back
- D. Leave the ear undisturbed
Correct Answer: A
Rationale: For children under 3, pulling the ear down and back straightens the ear canal for proper administration of ear drops.
The nurse is caring for a client with a wound that presents with full-thickness tissue loss and eschar covering the wound bed. The nurse would record this wound as which stage?
- A. Stage I
- B. Stage II
- C. Stage III
- D. Stage IV
- E. unstageable
Correct Answer: E
Rationale: A wound with eschar covering the bed is unstageable because the depth cannot be assessed until the eschar is removed.
A client is admitted with a diagnosis of duodenal ulcer. A common complaint of the client with a duodenal ulcer is:
- A. Epigastric pain that is relieved by eating
- B. Weight loss
- C. Epigastric pain that is worse after eating
- D. Vomiting after eating
Correct Answer: A
Rationale: Duodenal ulcers typically cause epigastric pain that is relieved by eating due to buffering of gastric acid.