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A client with a temperature of 39°C (102.2°F) and a rash is being evaluated. Which condition should the nurse consider?

A.

Meningococcal meningitis.

B.

Urinary tract infection.

C.

Gastroenteritis.

D.

Osteoarthritis.

Answer and Explanation

The Correct Answer is A

Choice A rationale

 

Meningococcal meningitis can present with a high fever (39°C or 102.2°F) and a rash, indicating a severe bacterial infection.

 

Choice B rationale

 

Urinary tract infections typically present with urinary symptoms, not a rash.

 

Choice C rationale

 

Gastroenteritis presents with gastrointestinal symptoms, not a rash.

 

Choice D rationale

 

Osteoarthritis is a degenerative joint disease and does not cause fever or rash.
 


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Correct Answer is D

Explanation

Choice A rationale

Poor blood glucose control is a significant factor in delayed wound healing in patients with diabetes. Hyperglycemia impairs various aspects of the immune response, reduces blood flow, and increases the risk of infection, all of which contribute to delayed healing.

Choice B rationale

Inadequate protein intake can also contribute to delayed wound healing. Protein is essential for the repair and regeneration of tissues, and a deficiency can impair the body’s ability to heal wounds effectively.

Choice C rationale

Peripheral neuropathy, a common complication of diabetes, can lead to decreased sensation in the feet, making it more likely for injuries to go unnoticed and untreated. This can result in chronic wounds and delayed healing.

Choice D rationale

All of the above factors—poor blood glucose control, inadequate protein intake, and peripheral neuropathy—can contribute to delayed healing of foot ulcers in patients with diabetes. Each of these factors plays a role in the complex process of wound healing and can hinder the body’s ability to repair itself.

Correct Answer is C

Explanation

Choice A rationale

Administering diuretic medication as prescribed is an important intervention for managing fluid overload in heart failure. Diuretics help reduce fluid accumulation by increasing urine output, which can alleviate symptoms such as swelling and shortness of breath. However, before administering any medication, it is crucial to assess the client’s current respiratory status and oxygen saturation to determine the severity of their condition and ensure that the intervention is appropriate and safe.

Choice B rationale

Elevating the client’s legs can help reduce swelling in the lower extremities by promoting venous return and decreasing fluid accumulation. While this intervention can provide some relief, it does not address the immediate concern of the client’s respiratory status. Assessing the client’s respiratory status and oxygen saturation is a priority to ensure that they are receiving adequate oxygenation and to identify any potential respiratory distress that may require urgent intervention.

Choice C rationale

Assessing the client’s respiratory status and oxygen saturation is the first priority in this scenario. Heart failure can lead to pulmonary congestion and impaired gas exchange, resulting in shortness of breath and decreased oxygen levels. By assessing the client’s respiratory status and oxygen saturation, the nurse can determine the severity of the client’s condition, identify any immediate respiratory needs, and implement appropriate interventions to improve oxygenation and respiratory function.

Choice D rationale


Restricting fluid intake is a common intervention for managing fluid overload in heart failure. By limiting fluid intake, the nurse can help prevent further fluid accumulation and reduce the risk of worsening symptoms. However, this intervention does not address the immediate concern of the client’s respiratory status. Assessing the client’s respiratory status and oxygen saturation is a priority to ensure that they are receiving adequate oxygenation and to identify any potential respiratory distress that may require urgent intervention.

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