Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A young man with malaria spikes a temperature of 105°F (40.5°C) and begins to hallucinate. How should the nurse assess this?
A. Delirium
Delirium: Delirium is characterized by acute confusion, disorientation, and altered mental status often due to severe infection or high fever.
B. Psychotic break
Psychotic break: While hallucinations are a symptom, a psychotic break is generally a chronic mental health condition rather than an acute response to infection.
C. Possible stroke
Possible stroke: Stroke symptoms usually involve sudden onset of neurological deficits rather than fever and hallucinations.
D. Anxiety disorder
Anxiety disorder: Anxiety disorders do not typically cause such high fevers or acute hallucinations.
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Full Explanation
A. Delirium: Delirium is characterized by acute confusion, disorientation, and altered mental status often due to severe infection or high fever.
B. Psychotic break: While hallucinations are a symptom, a psychotic break is generally a chronic mental health condition rather than an acute response to infection.
C. Possible stroke: Stroke symptoms usually involve sudden onset of neurological deficits rather than fever and hallucinations.
D. Anxiety disorder: Anxiety disorders do not typically cause such high fevers or acute hallucinations.
Similar Questions
Several residents in a long term care facility have been diagnosed with herpes zoster. Which resident will require the closest observation for development of complications?
A. A resident with dementia who requires assistance eating.
A resident with dementia who requires assistance eating: While this resident might have complications due to a weakened immune system, chemotherapy significantly increases the risk of complications from herpes zoster.
B. A resident who is sexually active
A resident who is sexually active: Sexual activity does not increase the risk of complications from herpes zoster.
C. A resident who is undergoing chemotherapy for breast cancer
A resident who is undergoing chemotherapy for breast cancer: Chemotherapy significantly compromises the immune system, making the resident more susceptible to severe complications from herpes zoster.
D. A resident recovering from a hip fracture
A resident recovering from a hip fracture: While recovering from a hip fracture is a stressor, it does not have as significant an impact on the immune system as chemotherapy.
Full Explanation
A. A resident with dementia who requires assistance eating: While this resident might have complications due to a weakened immune system, chemotherapy significantly increases the risk of complications from herpes zoster.
B. A resident who is sexually active: Sexual activity does not increase the risk of complications from herpes zoster.
C. A resident who is undergoing chemotherapy for breast cancer: Chemotherapy significantly compromises the immune system, making the resident more susceptible to severe complications from herpes zoster.
D. A resident recovering from a hip fracture: While recovering from a hip fracture is a stressor, it does not have as significant an impact on the immune system as chemotherapy.
The nurse recommends a breathing technique to help a patient with chronic obstructive pulmonary disease (COPD) to empty the lungs of used air and to promote inhalation of adequate oxygen. What is this method of breathing called?
A. Decreased expiration
Decreased expiration: This term does not refer to a specific breathing technique used for COPD.
B. Pursed-lip breathing
Pursed-lip breathing: Pursed-lip breathing helps patients with COPD to maintain open airways, increase expiratory time, and improve oxygen exchange.
C. Increased Inspiration
Increased Inspiration: This term is not a recognized technique and may lead to incorrect breathing practices.
D. Vital capacity
Vital capacity: Vital capacity is a measure of lung volume and is not a breathing technique.
Full Explanation
A. Decreased expiration: This term does not refer to a specific breathing technique used for COPD.
B. Pursed-lip breathing: Pursed-lip breathing helps patients with COPD to maintain open airways, increase expiratory time, and improve oxygen exchange.
C. Increased Inspiration: This term is not a recognized technique and may lead to incorrect breathing practices.
D. Vital capacity: Vital capacity is a measure of lung volume and is not a breathing technique.
A young adult patient has come into a dermatology clinic and reports having had a single 1-in lesion that was scaly with a raised border and a pink center on the chest. Now, a little more than a week later, there are smaller matching spots of the rash on both sides of the chest. The nurse observes pink, oval-shaped spots that are 1⁄4 to 1⁄2 in across. What condition does the nurse suspect the health care provider will diagnose?
A. Pityriasis rosea
Pityriasis rosea typically starts with a single, larger "herald patch" followed by a rash with smaller, oval spots. The described pattern is characteristic of this condition.
B. Herpes zoster virus
Herpes zoster virus or shingles, usually presents with vesicular lesions in a dermatomal distribution, rather than scattered oval spots.
C. Herpes simplex type 1
Herpes simplex type 1 generally causes oral lesions or cold sores, not the body rash described.
D. Impetigo contagiosa
Impetigo contagiosa is a bacterial infection that typically causes honey-colored crusted sores and is not described as having a herald patch or oval spots.
Full Explanation
A. Pityriasis rosea typically starts with a single, larger "herald patch" followed by a rash with smaller, oval spots. The described pattern is characteristic of this condition.
B. Herpes zoster virus or shingles, usually presents with vesicular lesions in a dermatomal distribution, rather than scattered oval spots.
C. Herpes simplex type 1 generally causes oral lesions or cold sores, not the body rash described.
D. Impetigo contagiosa is a bacterial infection that typically causes honey-colored crusted sores and is not described as having a herald patch or oval spots.