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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 enters the room of a woman who had a vaginal hysterectomy three days ago and finds her crying. What is the best initial approach for the nurse?

Correct Answer: A

Rationale: Asking about her concerns opens therapeutic communication, addressing her emotional needs directly and empathetically.

Question 3 of 5

A culture is taken of a lesion suspected of being herpes. The nurse knows that the specimen:

Correct Answer: A

Rationale: Herpes culture specimens should be packed on ice to preserve the virus for accurate laboratory testing.

Question 4 of 5

The nurse is caring for an elderly client after hip replacement surgery. The client is distressed because he has not had a bowel movement in 3 days. Which action by the nurse would be most appropriate?

Correct Answer: D

Rationale: A focused abdominal assessment determines the cause of constipation (e.g., impaction, obstruction) before interventions like laxatives, dietary changes, or RN notification, ensuring safe and targeted care.

Question 5 of 5

Damage to the VIII cranial nerve results in:

Correct Answer: B

Rationale: The VIII cranial nerve (vestibulocochlear) is responsible for hearing and balance; damage causes sensorineural hearing loss, affecting the inner ear or nerve pathways.

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