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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 is caring for a client who had a seizure 10 minutes ago. The client is now confused and reports a headache. Which of the following phases of seizure activity should the nurse recognize the client is experiencing?

Correct Answer: C

Rationale: The postictal phase follows a seizure, characterized by confusion and headache as the brain recovers. Ictal is the seizure itself, aural involves pre-seizure sensations, and prodromal is vague premonitory symptoms.

Question 3 of 5

A nurse is performing a dressing change for a hospitalized client with an infected surgical incision. Which actions should the nurse take?

Correct Answer: C

Rationale: Clean gloves for removing soiled dressings prevent contamination, while sterile gloves for applying the new dressing maintain a sterile field. Full PPE is excessive for removal, and clean gloves for application risk infection.

Question 4 of 5

The nurse is caring for a client who is very demanding. She frequently rings the bell and asks to have her pillow fluffed or the water glass filled. Which response by the nurse will likely be most effective?

Correct Answer: D

Rationale: Acknowledging potential underlying concerns invites the client to express needs, reducing demands. Constant responses reinforce behavior, and dismissive or confrontational responses escalate tension.

Question 5 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.

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