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Questions 164

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Question 1 of 5

The nurse is talking with the parent of a 14-month-old client who was exposed to measles 2 days ago. The client has not received the measles, mumps, and rubella (MMR) vaccine. Which of the following statements would be most appropriate for the nurse to make?

Correct Answer: A

Rationale: Post-exposure MMR vaccination within 72 hours can prevent measles in unvaccinated individuals. Monitoring temperature or assuming no symptoms means no infection is incorrect, as measles has an incubation period. Measles spreads via respiratory droplets, not just rash contact.

Question 2 of 5

A 2-year-old in the emergency department is suspected of having intussusception. Which assessment finding should the nurse expect?

Correct Answer: C

Rationale: Intussusception causes intestinal obstruction, often leading to 'currant jelly' stools (blood and mucus). Black, sticky stools suggest upper GI bleeding. Greasy stools indicate malabsorption. Ribbon-like stools suggest rectal narrowing.

Question 3 of 5

The nurse's neighbor has a total cholesterol of 450 mg/dL. The neighbor asks the nurse what this means. What should the nurse include when responding?

Correct Answer: C

Rationale: A cholesterol level of 450 mg/dL is significantly elevated, increasing cardiovascular risk, requiring medical consultation.

Question 4 of 5

The nurse is talking with the spouse of a client who is eligible for hospice care. The spouse states, 'I do not know if I can make this decision. What would you do?' Which of the following responses would be appropriate for the nurse to make?

Correct Answer: A

Rationale: The nurse should remain neutral and facilitate discussion about the client's values and preferences, helping the spouse make an informed decision without personal bias or directing to other resources prematurely.

Question 5 of 5

The nurse is experiencing repeated unwanted sexual advances from a health care provider (HCP). Which of the following actions should the nurse take? Select all that apply.

Correct Answer: A,B,C,D

Rationale: Seeking support aids coping, reviewing policy clarifies procedures, reporting to a supervisor initiates formal action, and documentation provides evidence. Confronting outside work risks escalation and is unsafe.

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