A nurse working in the emergency department is admitting a client who has pertussis. Which of the following actions should the nurse take?

Perform a Mantoux skin test on the client.

Assign the client to a negative-pressure airflow room.

Wear a surgical mask when providing care to the client.

Recommend that the client's family members receive antiviral therapy.

Answer and Explanation

The Correct Answer is C

The correct answer is: c. Wear a surgical mask when providing care to the client.

Choice A: Perform a Mantoux skin test on the client

The Mantoux skin test is used to screen for tuberculosis, not pertussis. Pertussis, also known as whooping cough, is a bacterial infection caused by Bordetella pertussis. The Mantoux test would not be relevant or helpful in diagnosing or managing pertussis.

Choice B: Assign the client to a negative-pressure airflow room

Negative-pressure airflow rooms are typically used for airborne infections such as tuberculosis, measles, or varicella. Pertussis is primarily spread through respiratory droplets, not airborne transmission, so a negative-pressure room is not necessary.

Choice C: Wear a surgical mask when providing care to the client

Wearing a surgical mask is appropriate when caring for a client with pertussis. Pertussis is spread through respiratory droplets, and wearing a mask helps prevent the transmission of the bacteria to healthcare workers and other patients.

Choice D: Recommend that the client’s family members receive antiviral therapy

Antiviral therapy is not effective against pertussis, which is a bacterial infection. Instead, antibiotics such as azithromycin or erythromycin are used to treat pertussis and prevent its spread. Therefore, recommending antiviral therapy would not be appropriate.

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Correct Answer is C

Explanation

Choice A reason: Cheyne-Stokes respirations, characterized by a pattern of irregular breathing with periods of apnea, can be a sign of brain stem compression due to increased intracranial pressure. However, it is not typically the first sign of deteriorating neurological status.

Choice B reason: Pupillary dilation, especially if it is unilateral, can indicate pressure on the cranial nerves due to increased intracranial pressure. It is a concerning sign but may not be the first to appear as neurological function deteriorates.

Choice C reason: An altered level of consciousness is often the first sign of deteriorating neurological status in a patient with increased intracranial pressure. Changes in consciousness can range from slight disorientation or confusion to complete unresponsiveness.

Choice D reason: Decorticate posturing, which involves abnormal flexion of the arms with extension of the legs, indicates significant brain injury and is a later sign of increased intracranial pressure, not typically the first sign.

A. 1 cup white rice B. 1/2 cup nonfat yogurt C. 1 medium baked potato with skin D. 2 tbsp peanut butter

Correct Answer is A

Explanation

Choice A reason: White rice is considered a low-potassium food, making it a suitable option for someone with chronic kidney disease who needs to limit their potassium intake. One cup of cooked white rice contains approximately 54 mg of potassium, which is significantly lower than the other options listed.

Choice B reason: Nonfat yogurt can vary in potassium content, but on average, a 1/2 cup serving may contain around 200 to 300 mg of potassium. While it is a nutritious choice, it contains more potassium than white rice and should be consumed in moderation by individuals with potassium restrictions.

Choice C reason: A medium baked potato with skin is high in potassium, with one potato containing over 900 mg of potassium. This makes it an unsuitable choice for someone who needs to limit their potassium intake due to chronic kidney disease.

Choice D reason: Peanut butter contains a moderate amount of potassium. Two tablespoons of peanut butter can have around 150 to 200 mg of potassium. Although it's not as high in potassium as a baked potato, it still contains more potassium than white rice.

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A nurse working in the emergency department is admitting a client who has pertussis. Which of the following actions should the nurse take?

Choice A: Perform a Mantoux skin test on the client

Choice B: Assign the client to a negative-pressure airflow room

Choice C: Wear a surgical mask when providing care to the client

Choice D: Recommend that the client’s family members receive antiviral therapy

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has increased intracranial pressure. The nurse should recognize that which of the following is the first sign of deteriorating neurological status?

Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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