When assessing the client's hair, you are especially looking for pediculosis capitis. If it is present, which of the following signs will you most likely find?

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Question 1 of 5

When assessing the client's hair, you are especially looking for pediculosis capitis. If it is present, which of the following signs will you most likely find?

Correct Answer: A

Rationale: Pediculosis capitis (head lice) shows oval nits resembling dandruff on hairs, not crusts, lesions, or visible insects (lice move). Nurses identify this for treatment planning.

Question 2 of 5

Which assessment finding indicates the need for assistive devices during mobilization and transfers?

Correct Answer: C

Rationale: A history of falls and unsteady gait signals the need for assistive devices like walkers during mobilization, highlighting instability and fall risk in transfers. Strong muscles, full joint motion, or upper body strength suggest less need, but past incidents outweigh these. Nurses assess this to tailor safety measures, ensuring devices support patients with proven mobility challenges, preventing further injuries effectively.

Question 3 of 5

A nurse is providing oxygen therapy to a client with chronic obstructive pulmonary disease (COPD). Which oxygen delivery system would be most appropriate for this client?

Correct Answer: B

Rationale: A Venturi mask (B) is most appropriate for COPD, delivering precise oxygen (24-50%) to maintain SpO2 88-92%, avoiding suppression of hypoxic drive. Nasal cannula (A) lacks precision. Non-rebreather (C) risks high oxygen, reducing respiratory drive. Oxygen tent (D) is impractical. Controlled delivery aligns with GOLD standards, balancing oxygenation and CO2 retention.

Question 4 of 5

The nurse is caring for a client receiving oxygen therapy via a face tent. Which action by the nurse is important to ensure proper oxygen delivery?

Correct Answer: C

Rationale: Frequently checking for condensation (C) in a face tent ensures unobstructed oxygen flow, as buildup reduces delivery. Snug fit (A) restricts airflow in tents. Nose breathing (B) isn't required tents cover both. Q8h SpO2 (D) is too infrequent. Condensation checks, per nursing standards, maintain therapy effectiveness.

Question 5 of 5

A client with schizophrenia is receiving chlorpromazine (Thorazine) 400 mg twice a day. An adverse side effect of the medication is:

Correct Answer: B

Rationale: Chlorpromazine, an antipsychotic, can cause elevated temperature as an adverse effect, linked to neuroleptic malignant syndrome or anticholinergic effects disrupting thermoregulation a serious risk requiring monitoring. Photosensitivity, weight gain, or hypertension are possible but less acute. Nurses watch for fever to intervene swiftly, ensuring client safety during schizophrenia treatment.

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