A client with a temperature of 39°C (102.2°F) and a rash is being evaluated. Which condition should the nurse consider?
Meningococcal meningitis.
Urinary tract infection.
Gastroenteritis.
Osteoarthritis.
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 A
Explanation
Choice A rationale
A blood pressure reading of 180/120 mmHg or higher is indicative of a hypertensive crisis. This condition requires immediate medical attention to prevent damage to vital organs such as the heart, kidneys, and brain.
Choice B rationale
A heart rate of 90 beats per minute is within the normal range and does not indicate a hypertensive crisis. While it is important to monitor heart rate, it is not a definitive sign of a hypertensive emergency.
Choice C rationale
A respiratory rate of 20 breaths per minute is within the normal range and does not indicate a hypertensive crisis. Respiratory rate alone is not a reliable indicator of hypertensive emergencies.
Choice D rationale
A temperature of 37°C (98.6°F) is normal and does not indicate a hypertensive crisis. Body temperature is not a primary indicator of hypertensive emergencies.
Correct Answer is B
Explanation
Choice A rationale
Decreasing the secretion of thyroid stimulating hormone (TSH) by the pituitary gland is not a compensatory response to fluid volume deficit. TSH primarily regulates thyroid function and metabolism, and its secretion is not directly related to fluid balance or osmolality.
Choice B rationale
Increasing renin-angiotensin-aldosterone system (RAAS) activity by the kidneys is the body’s primary compensatory response to fluid volume deficit. When there is a decrease in blood volume or blood pressure, the kidneys release renin, which activates the RAAS. This system increases the reabsorption of sodium and water in the kidneys, leading to an increase in blood volume and blood pressure.
Choice C rationale
Decreasing the secretion of cortisol by the adrenal gland is not a compensatory response to fluid volume deficit. Cortisol is a stress hormone that helps regulate metabolism, immune response, and other functions, but it is not directly involved in fluid balance.
Choice D rationale
Increasing the secretion of natriuretic peptides by the heart is a response to fluid overload, not fluid deficit. Natriuretic peptides promote the excretion of sodium and water by the kidneys, which helps reduce blood volume and pressure. This response is opposite to what is needed in a fluid volume deficit situation.