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Questions 164

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Question 1 of 5

A father brings his 17-year-old son to a walk-in clinic. The client reports a sudden severe headache. He has a temperature of 104°F and a purple rash. What is the best action for the nurse at this time?

Correct Answer: C

Rationale: Symptoms suggest meningococcal meningitis, a medical emergency requiring isolation and immediate physician notification.

Question 2 of 5

The nurse reports that a client with a Mantoux test has an induration of 10 mm. The nurse knows that the induration indicates:

Correct Answer: B

Rationale: A 10 mm induration indicates exposure to the tubercle bacillus, requiring further evaluation to determine active infection.

Question 3 of 5

The clinic nurse is reinforcing instructions to a client who will be wearing a Holter monitor for the next 24 hours. Which instructions are important to review with the client?

Correct Answer: B

Rationale: Keeping a diary of activities and symptoms correlates events with cardiac readings, aiding diagnosis. Transmitting readings is not client responsibility, and Holter monitors are typically worn continuously, including during bathing.

Question 4 of 5

The nurse is caring for a client who was admitted for treatment of schizoaffective disorder with visual hallucinations. He tells the nurse that he sees extraterrestrials that are coming to get him. What is the best nursing response?

Correct Answer: D

Rationale: Reflecting the client's statement validates his experience without reinforcing the hallucination, promoting therapeutic communication.

Question 5 of 5

A client is admitted to the burn unit with an electrical burn. Which of the following areas probably sustained the greatest degree of injury?

Correct Answer: B

Rationale: Electrical burns cause deep tissue damage, with intrathoracic organs (heart, lungs) at greatest risk due to the current's path through the body.

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