Patient Data
For each nursing intervention, click to indicate whether the action is appropriate or not appropriate for this client. Each row must have only one response option selected.

Maintain strict bedrest.

Isolate until fifth day of rash.

Apply loose-fitting clothing.

Encourage soft, bland foods.

Restrict oral intake.

Answer and Explanation

The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"}}

Rationale:

• Maintain strict bedrest: Strict bedrest is not required for an infant with measles who is hemodynamically stable and able to move independently. Activity should be allowed as tolerated to promote comfort and normal development. Forced immobility may increase irritability and distress. Rest is encouraged, but strict bedrest is unnecessary.

• Isolate until fifth day of rash: Measles is highly contagious and requires airborne isolation to prevent transmission. Clients are considered infectious from four days before to four days after rash onset, making isolation through the fifth day essential. Initiating and maintaining isolation protects other patients, caregivers, and healthcare staff. This intervention aligns with infection control guidelines for measles management.

• Apply loose-fitting clothing: Loose-fitting clothing helps reduce skin irritation and discomfort associated with the maculopapular rash. It also allows better heat dissipation in a febrile child, supporting temperature regulation. Tight clothing could worsen skin discomfort and increase irritability. Comfort-focused care is appropriate in viral illnesses like measles.

• Encourage soft, bland foods: The child has decreased appetite, nausea, and oral lesions consistent with Koplik spots, which can make chewing painful. Soft, bland foods reduce oral discomfort and support adequate nutritional intake. Maintaining nutrition aids recovery and prevents further fatigue. This intervention supports comfort and hydration without causing additional irritation.

• Restrict oral intake: Restricting oral intake increases the risk of dehydration, especially in a febrile infant with tachypnea. Adequate fluids are essential to maintain hydration and support metabolic demands during infection. Encouraging fluids is more appropriate than limiting intake.

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is B

Explanation

Rationale:
A. Initiate peripheral IV (PIV) access: IV access is important for management of a thyroid crisis, but assessment takes priority before initiating interventions. The client’s sudden apprehension, restlessness, and heat intolerance suggest acute physiologic instability. Vital signs are needed to determine the severity of the condition and guide urgent treatment.

B. Obtain a complete set of vital signs: Thyroid crisis (thyroid storm) is characterized by hyperthermia, tachycardia, hypertension, and possible dysrhythmias. Rapid assessment of temperature, heart rate, blood pressure, and respiratory status is critical to identify life-threatening instability. This action establishes the urgency and directs immediate interventions.

C. Access laboratory results to confirm a thyroid crisis: Thyroid storm is a clinical diagnosis based on symptoms and vital signs rather than laboratory confirmation. Waiting for lab results delays urgent care. Immediate assessment and stabilization take precedence over diagnostic confirmation.

D. Encourage relaxation and slow deep breathing: Anxiety and restlessness are physiologic manifestations of excess thyroid hormone, not primarily psychogenic. Relaxation techniques do not address the underlying hypermetabolic state. This approach risks delaying recognition of a medical emergency.

A. Left lower extremity pain and cramping after activity B. Cool, shiny, hairless left leg with delayed capillary refill C. Numbness and tingling in the left lower extremity D. Dependent rubor of the left foot E. History of type 2 diabetes mellitus F. Intermittent productive cough for 20 years G. Edema in the left lower extremity

Correct Answer is ["A","B","C","D"]

Explanation

Rationale:
A. Left lower extremity pain and cramping after activity: Pain and cramping with ambulation, especially worsening and lasting longer than usual, indicate intermittent claudication and potential progression of peripheral arterial disease (PAD). This is a priority concern because it reflects impaired perfusion and ischemia.

B. Cool, shiny, hairless left leg with delayed capillary refill: These signs indicate chronic arterial insufficiency and decreased tissue perfusion. The risk of tissue damage, ulceration, or gangrene makes this a high-priority nursing concern.

C. Numbness and tingling in the left lower extremity: Neurologic symptoms such as paresthesia reflect ischemia and nerve compromise. Prompt assessment and monitoring are essential to prevent complications like peripheral neuropathy or tissue injury.

D. Dependent rubor of the left foot: Dependent rubor is a classic sign of PAD indicating poor arterial blood flow and oxygenation. This is an urgent finding that reflects vascular compromise and risk for critical limb ischemia.

E. History of type 2 diabetes mellitus: While diabetes is an important risk factor for PAD, it is a chronic condition rather than an immediate priority for acute nursing concern in this admission.

F. Intermittent productive cough for 20 years: Chronic cough may indicate COPD or chronic bronchitis, but it is not the immediate priority compared to signs of acute limb ischemia.

G. Edema in the left lower extremity: Mild dependent edema is noted but is likely secondary to positioning rather than a primary vascular concern. It is lower priority compared with ischemic signs and symptoms.

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Patient Data For each nursing intervention, click to indicate whether the action is appropriate or not appropriate for this client. Each row must have only one response option selected.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

Patient Data Based on the client’s history and assessment findings, which of the following are priority nursing concerns for this client? Select all that apply.

Correct Answer is ["A","B","C","D"]

Explanation

A client on the mental health unit has been scowling and rapidly pacing up and down the hall for several minutes. Which behaviors are most important for the nurse to monitor?

Patient Data For each potential nursing action, click to indicate whether the action is indicated, contraindicated, or nonessential for this client's plan of care. Each row must have only one option selected.

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Patient Data
For each nursing intervention, click to indicate whether the action is appropriate or not appropriate for this client. Each row must have only one response option selected.