Nursing fundamental practice question

The nurse expects a client with an elevated temperature to exhibit what indicators of pyrexia? Select all that apply. Dyspnea Flushed face Precordial pain Increased pulse rate Increased blood pressure

Flushed face; increased pulse rate High body temperature will have vasodilation and increase heart rate to meat cooling demand

A senior high school student, whose immunization status is current, asks the school nurse which immunizations will be included in the precollege physical. Which vaccine should the nurse tell the student to expect to receive? Hepatitis C (HepC) 2 Influenza type B (HIB) 3 Measles, mumps, rubella (MMR) 4 Diphtheria, tetanus, pertussis (DTaP)

Measles, mumps, rubella Individuals born after 1956 should receive one additional dose of MMR vaccine if they are students in postsecondary educational institutions. Currently there is no vaccine for hepatitis C. The HIB immunization is unnecessary. If the student received an additional DTaP at age 12, it is not necessary. A booster dose of tetanus toxoid (Td) should be received every 10 years.

A nurse is caring for an elderly client with dementia who has developed dehydration as a result of vomiting and diarrhea. Which assessment best reflects the fluid balance of this client? 1 Skin turgor 2 Intake and output results 3 Client's report about fluid intake 4 Blood lab results

Blood lab results provide objective data about fluid and electrolyte status, as well as about hemoglobin and hematocrit. Skin turgor is not a reliable indicator of hydration status for the elderly client because it is generally decreased with age. Intake and output results provide data only about fluid balance, but do not present a comprehensive picture of the client's fluid and electrolyte status; therefore this is not the best answer. The client's report about fluid intake is subjective data in general and not reliable because this client has dementia and therefore has memory problems.

A client with severe bleeding due to a motor vehicle accident was admitted to the emergency department. The nurse assessed that the client was unconscious and the healthcare provider diagnosed the client with a hand fracture. The client is receiving oxygen therapy as well as intravenous fluids through the antecubital fossa. Which sites should be used to obtain the client's pulse rate? Select all that apply. 1 Apical 2 Carotid 3 Brachial 4 Femoral 5 Popliteal

Carotid; Femoral Pts with risk of hypovolemic shock may not have palpaple pulses at other locations. Because of the IV at antercubital fossa, brachial pulse should be avoided. Apical pulses cannot be palpated in hypovolemic shock risk/bleeding pts but can be ascultated - which is not a choice

A nurse is teaching a male client about measures to maintain sexual health and prevent transmission of sexually transmitted infections (STI). Which statement of the client indicates effective learning? 1 "I will use condoms when having sex with an infected partner." 2 "I will perform a genital self-examination every month before bathing." 3 "I will refrain from getting the human papilloma virus vaccine (HPV) before the age of 27 years." 4 "I will consult with my primary healthcare provider when there is a rash or ulcer on my genitalia."

The client should consult a primary healthcare provider when there is a rash or ulcer on genitalia because these are the warning signs of a sexually transmitted infection (STI). Having sex with an infected partner with or without using condoms may increase the risk of contracting an STI. A male client should perform a genital self-examination every month after taking a bath, when the scrotal skin is less thick. The human papilloma virus vaccine (HPV) vaccine should be taken between 9 and 26 years of age.

While assessing a pediatric client, an ophthalmologist notices that the child is unable to focus on an object with both eyes simultaneously. Which other findings in the client confirms the diagnosis as strabismus? Select all that apply. 1 Impaired near vision 2 Crossed appearance of eyes 3 Elevated intraocular pressure 4 Impaired extraocular muscles 5 Degeneration of central retina

crossed eyes appearance; impaired extraocular muscles Strabismus is a congenital condition in which both eyes do not focus on an object simultaneously, resulting in a crossed appearance of the eyes. This condition is caused by impaired extraocular muscles. Impaired near vision is associated with hyperopia or presbyopia. Elevated intraocular pressure results in glaucoma. Macular degeneration is caused by degeneration of the central retina.