a patient presents with vesicles covering the upper torso which of the following situations could cause this condition
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Nursing Elites

NCLEX-RN

Exam Cram NCLEX RN Practice Questions

1. A patient presents with vesicles covering the upper torso. Which of the following situations could cause this condition?

Correct answer: Sunburn

Rationale: Vesicles are fluid-filled blisters. In the context of the upper torso, the presentation of vesicles suggests a second-degree sunburn. Sunburn can cause blistering, leading to the formation of vesicles. Choice A, 'Knife fight,' does not align with the presentation of vesicles on the upper torso due to trauma. Choice B, 'Auto accident,' is more likely to cause abrasions or bruises rather than vesicles. Choice D, 'Fungal infection,' typically presents with other symptoms such as redness, itching, or scaling, but not vesicles on the upper torso.

2. A patient is on bedrest 24 hours after a hip fracture. Which regular assessment or intervention is essential for detecting or preventing the complication of Fat Embolism Syndrome?

Correct answer: Assess the patient's mental status for drowsiness or sleepiness.

Rationale: In detecting or preventing Fat Embolism Syndrome (FES), assessing the patient's mental status for drowsiness or sleepiness is crucial. Decreased level of consciousness is an early sign of FES due to decreased oxygen levels. Performing passive, light range-of-motion exercises on the hip may not directly relate to FES. Assessing pedal pulse and capillary refill in the toes is essential for assessing circulation but not specific to detecting FES. Administering a stool softener, while important for preventing constipation in immobilized patients, is not directly related to detecting or preventing FES.

3. The nurse assesses a patient suspected of having meningitis. Which of the following is a common clinical manifestation of this condition?

Correct answer: A high WBC count and decreased level of consciousness

Rationale: The correct answer is 'A high WBC count and decreased level of consciousness.' Meningitis is often caused by an infectious organism, leading to an increase in Intracranial Pressure (ICP), which can result in decreased level of consciousness. While meningitis can trigger an inflammatory response, it typically presents with an elevated white blood cell (WBC) count rather than a low WBC count. Manic activity is not a common clinical manifestation of meningitis; instead, patients may exhibit altered mental status, confusion, or lethargy.

4. Which of the following glands found in the skin secretes a liquid called Sebum?

Correct answer: B: Sebaceous Glands

Rationale: Sebum is a liquid secreted by glands in the skin known as sebaceous glands. Sebum's primary function is to lubricate the skin and help maintain its integrity. Apocrine glands secrete a different type of sweat that is odorless but can develop an odor when combined with bacteria on the skin. Lacrimal glands produce tears to keep the eyes moist, and sweat glands secrete sweat to regulate body temperature through evaporation. Therefore, the correct answer is Sebaceous Glands because they specifically secrete sebum, distinguishing them from the other gland types mentioned.

5. The healthcare professional is taking the health history of a patient being treated for sickle cell disease. After being told the patient has severe generalized pain, the healthcare professional expects to note which assessment finding?

Correct answer: Yellow-tinged sclera

Rationale: In patients with sickle cell disease, severe generalized pain can be associated with vaso-occlusive crises, but yellow-tinged sclera is a common clinical finding related to sickle cell disease. This yellowing of the sclera, known as jaundice, occurs due to the release of bilirubin from damaged or destroyed red blood cells. Severe and persistent diarrhea is not a typical assessment finding in sickle cell disease. Intense pain in the toe may be associated with vaso-occlusive crisis but is not the expected assessment finding in this scenario. Headache is a common symptom in many conditions but is not specifically related to the assessment finding expected in a patient with sickle cell disease presenting with severe generalized pain.

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