Nursing Elites

1. A nonimmunized child appears at the clinic with a visible rash. Which of the following observations indicates the child may have rubeola (measles)?

• A. Small blue-white spots are visible on the oral mucosa.
• B. The rash begins on the trunk and spreads outward.
• C. There is low-grade fever.
• D. The lesions have a "teardrop-on-a-rose-petal"? appearance.

Correct answer: A

Rationale: The presence of small blue-white spots on the oral mucosa, known as Koplik's spots, is characteristic of measles (rubeola) infection. These spots typically appear on the buccal mucosa opposite the second molars, 1-2 days before the rash onset, and last until 2 days after the rash appears. While Koplik's spots are pathognomonic for measles, their absence does not rule out the diagnosis. Therefore, choice A is the correct answer. Choices B, C, and D are incorrect because the rash pattern, presence of low-grade fever, and characteristic appearance of lesions are not specific indicators of measles infection.

2. Which of the following nursing interventions is appropriate for a client suffering from a fever?

• A. Avoid withholding food from the client
• B. Increase the client's fluid intake
• C. Provide oxygen
• D. All answers are correct

Correct answer: B

Rationale: The appropriate nursing intervention for a client suffering from a fever is to increase the client's fluid intake. A fever can elevate the body's metabolism, leading to increased breathing and heart workload. This can result in fluid loss due to heightened respiration and sweating. Moreover, the augmented heart workload may necessitate more oxygen to maintain tissue perfusion. Providing oxygen and increasing fluid intake help meet the body's heightened demands during a fever. Withholding food from the client is inappropriate as proper nutrition is crucial for recovery, and providing oxygen alone may not address the fluid and metabolic demands associated with fever. Therefore, the correct choice is to increase the client's fluid intake.

3. Which risk factor places patients and residents at the greatest risk for falls?

• A. Old age
• B. Middle age
• C. Pneumonia
• D. COPD

Correct answer: A

Rationale: Old age is a significant risk factor for falls as elderly individuals are more prone to falls due to factors like decreased balance, muscle strength, and vision. Middle age is less associated with falls compared to old age. Pneumonia and COPD are medical conditions that are not direct risk factors for falls, unlike aging which significantly increases the risk of falls.

4. The key to the prevention of a pandemic influenza is:

• A. Early detection
• B. Early antibiotic treatment
• C. Vaccination of at-risk populations
• D. Isolation of suspected cases

Correct answer: A

Rationale: The key to preventing a pandemic influenza is early detection. Detecting influenza cases early allows for timely public health responses to limit the spread of the virus. Early detection helps in implementing measures such as isolation, treatment, and vaccination to prevent the development of a full-blown pandemic. Antibiotics are not effective against influenza viruses, so early antibiotic treatment is not the key to prevention. While vaccination of at-risk populations is important in controlling the spread of influenza, early detection is crucial as it allows for timely implementation of vaccination strategies. Isolation of suspected cases is a containment measure rather than a prevention strategy; the key to prevention lies in early detection to stop the spread before it becomes a pandemic.

5. A systemic sign of infection is ______________.

• A. swelling
• B. redness
• C. heat
• D. a lack of appetite

Correct answer: D

Rationale: The correct answer is 'a lack of appetite.' When a person experiences a systemic infection, they may exhibit signs that affect the entire body. A lack of appetite is a common systemic sign of infection, along with other symptoms like rapid pulse, fever, and an elevated white blood cell count. Swelling, redness, and heat are more indicative of localized inflammation or infection, rather than systemic involvement.

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