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Questions 164

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Question 1 of 5

The nurse is assessing a young child at a clinic visit for a mild respiratory infection. Koplik spots are noted on the oral mucous membranes. The nurse should then assess which area of the body?

Correct Answer: A

Rationale: The skin. A characteristic sign of rubeola is Koplik spots (small red spots with a bluish white center). These are found on the buccal mucosa about 2 days before and after the onset of the measles rash.

Question 2 of 5

The nurse is caring for a client with rheumatoid arthritis. Which of the following lifestyle modifications should the nurse recommend to the client?

Correct Answer: B,C,E

Rationale: Rest (
B), range-of-motion exercises (
C), and moist heat (E) manage rheumatoid arthritis symptoms. Ice (
A) can reduce inflammation, and a pillow under knees (
D) may worsen stiffness.

Question 3 of 5

The nurse is caring for a client who has chickenpox with open lesions. Which of the following infection control precautions should the nurse implement?

Correct Answer: A,B,C,D

Rationale: Chickenpox requires airborne and contact precautions: negative pressure room (
A), protecting pregnant staff (
B), masking during transport (
C), and gown, gloves, N95 (
D). Visitor restriction (E) is too short; it lasts until lesions crust.

Question 4 of 5

The client with a colostomy does not feel that the irrigating solution has drained completely. The nurse can enhance the effectiveness of the colostomy irrigation by telling the client to:

Correct Answer: A

Rationale: Gentle abdominal massage can stimulate peristalsis and help the irrigation solution drain completely from the colostomy. Reducing solution or using a heating pad is not standard, and increasing oral intake is unrelated.

Question 5 of 5

In a long term rehabilitation care unit, a client with spinal cord injury complains of a pounding headache. The client is sitting in a wheelchair watching television. Further assessment by the nurse reveals excessive sweating, a splotchy rash, pilomotor erection, facial flushing, congested nasal passages and a heart rate of 50. The nurse should perform which action next?

Correct Answer: C

Rationale: Check the client for bladder distention and the client's urinary catheter for kinks. These are findings of autonomic dysreflexia, typically initiated by a noxious stimulus below the level of injury such as a full bladder.

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