Nokea
Which subjective symptom is the client most likely to report to the nurse?
- A. Burning
- B. Pressure
- C. Vertigo
- D. Pain
Correct Answer: C
Rationale: Vertigo is a hallmark symptom of Meniere's disease due to inner ear fluid imbalance.
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When the client asks about the cause of shingles, the nurse answers correctly with which cause of the disease?
- A. The reactivation of a dormant virus
- B. A vector insect such as a tick
- C. A toxin from a bacterial infection
- D. An antibody response to a drug allergen
Correct Answer: A
Rationale: Shingles results from reactivation of the varicella-zoster virus.
The nurse is assessing the client diagnosed with scabies. Which assessment technique would be most appropriate?
- A. Gently palpate the affected area using sterile gloves.
- B. Apply vinegar to the affected area to identify the scabies.
- C. Use a magnifying glass and a penlight to visualize the skin.
- D. Obtain a Doppler to assess the movement of the mites.
Correct Answer: C
Rationale: Magnifying glass and penlight visualize scabies burrows and mites. Palpation is unnecessary, vinegar is irrelevant, and Doppler is for vascular assessment.
A severely burned man had his last tetanus shot when he started work at his job two years ago. What should the nurse expect to administer now?
- A. Tetanus toxoid booster
- B. Tetanus antitoxin
- C. Hyperimmune human tetanus globulin
- D. DPT booster
Correct Answer: A
Rationale: A tetanus toxoid booster is appropriate for a burn client with a tetanus shot within the past five years to ensure immunity against tetanus, common in burn wounds.
The nurse is caring for an adult who has herpes zoster. What medication is most likely to be administered to this client?
- A. Penicillin
- B. Acyclovir
- C. Tetracycline
- D. Benadryl
Correct Answer: B
Rationale: Acyclovir is the antiviral medication used to treat herpes zoster (shingles), reducing viral replication and symptom duration.
The nurse assesses that the client with partial-thickness burns over 50% of the total body surface area (TBSA) has gained weight and has generalized edema after the first 24 hours. The nurse should consider that the edema and weight gain are most likely related to which physiological processes?
- A. Elevated serum sodium and potassium levels
- B. Increased hemoglobin and hematocrit levels
- C. Excess intravenous fluid volume replacement
- D. Leakage of plasma into the interstitial space
Correct Answer: D
Rationale: Initially after a severe burn injury there is a loss of capillary integrity and a shift of fluid, sodium, and protein from the intravascular to the interstitial spaces. The body compensates for this interstitial hemoconcentration by retaining more fluid. Sodium is lost due to diuresis, and existing sodium tends to be diluted by an influx of fluid, so serum sodium levels will be decreased, not increased. Hgb and Hct levels may change in severe burns, but they are the result of the fluid shift, not the cause. Fluid volume deficit (not excess) is a major risk during this phase.