The school nurse is conducting pediculosis capitis checks. A child with a positive head check would have which finding?

Lesions in the scalp that extend to the hairline or neck.

Circular lesion with raised edges and central clearing and itching

White sacs attached to the hair shafts in the occipital area

Maculopapular lesions behind the ears.

Answer and Explanation

The Correct Answer is C

A.   While scratching due to lice can lead to irritation and lesions, this finding is not specific to pediculosis capitis. Lesions extending to the hairline or neck could be caused by various conditions, such as eczema or dermatitis, rather than lice infestation.
B.   This description is more characteristic of tinea capitis (scalp ringworm) rather than pediculosis capitis. Tinea capitis presents as circular patches with raised edges and may cause itching, but it is not caused by lice.
C.   In cases of pediculosis capitis, the white sacs refer to nits (lice eggs), which are commonly found attached to hair shafts, especially around the occipital area (back of the head). Nits are oval and may be mistaken for dandruff but are firmly attached to the hair.
D.   While maculopapular lesions can be a result of scratching, they are not a typical finding in pediculosis capitis. Such lesions might indicate another skin condition or an allergic reaction rather than an infestation of lice.

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Correct Answer is A

Explanation

A. DKA is characterized by the production of ketones, which can lead to a fruity or acetone-like odor on the breath. Additionally, the increased respiratory rate (Kussmaul breathing) occurs as the body attempts to compensate for metabolic acidosis by blowing off carbon dioxide.
B. While clients with diabetes may experience hunger, it is not a primary symptom of DKA. Hypotension (rather than hypertension) is more commonly observed due to dehydration and fluid loss associated with DKA.

C. Cold, clammy skin suggests the body is in a sympathetic state due to low blood sugar. While irritability can occur in various situations, it is not a hallmark sign of DKA.
D. Sweating and tremors are symptoms of low blood sugar levels and are not characteristic of DKA. In DKA, patients typically present with dry skin due to dehydration.

A. Apnea B. Tachypnea C. Bradypnea D. Orthopnea

Correct Answer is B

Explanation

A. Apnea refers to a temporary cessation of breathing. If a patient is experiencing apnea, there would be a complete stop in respiratory activity, which does not apply to a respiratory rate of 36 breaths per minute.
B. Tachypnea is defined as an increased respiratory rate, typically greater than 20 breaths per minute in adults. A respiratory rate of 36 breaths per minute falls well within this range, indicating that the patient is experiencing tachypnea.
C. Bradypnea refers to a decreased respiratory rate, usually defined as fewer than 12 breaths per minute. Since the patient’s rate is 36 breaths per minute, this option does not apply.
D. Orthopnea refers to difficulty breathing when lying flat and is not specifically related to the respiratory rate itself. It usually describes a positional dyspnea rather than a numerical measurement of breathing.

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The school nurse is conducting pediculosis capitis checks. A child with a positive head check would have which finding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with type 1 diabetes is admitted to the emergency department for DKA. Which assessment findings should the nurse expect to note?

Correct Answer is A

Explanation

A patient has a respiratory rate of 36 breaths per minute. How would the nurse describe this respiratory pattern?

Correct Answer is B

Explanation

The patient complaints of dyspnea and the nurse is concerned the patient may need oxygen. What assessment will the nurse perform to determine if the patient needs supplemental oxygen?

The nurse is conducting an initial interview, which specific data would be a priority risk factor for developing peptic ulcer disease?

A 3-year-old is admitted for repair of a fractured femur and is placed in Bryant's traction. Which finding by the nurse indicates that the traction is working properly?

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