A nurse is checking a school-age child for pediculosis capitis (head lice). Which of the following findings is a definitive indication of this condition?

Itching and scratching of the head

Patchy areas of hair loss

Firmly attached white particles on the hair

Thick, yellow-crusted lesions on a red base

Answer and Explanation

The Correct Answer is C

A. Itching and scratching of the head. While itching is a common symptom, it is not a definitive sign of head lice. Other conditions (e.g., dandruff, seborrheic dermatitis, or dry scalp) can also cause itching.

B. Patchy areas of hair loss. Hair loss is not a characteristic sign of head lice. It may indicate alopecia areata or tinea capitis (scalp ringworm) instead.

C. Firmly attached white particles on the hair. The presence of nits (lice eggs) that are firmly attached to the hair shaft near the scalp is a definitive sign of pediculosis capitis. Nits do not flake off like dandruff and are difficult to remove.

D. Thick, yellow-crusted lesions on a red base. This describes impetigo, a bacterial skin infection, not head lice.

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Correct Answer is A

Explanation

A. A reddened area over the sacrum. This is an early sign of a pressure ulcer, a common complication of immobility in bed-bound clients.

B. Difficulty moving the upper extremities. While weakness may occur after a stroke, this is not a complication of immobility but rather a direct effect of neurological damage.

C. Stiffness in the lower extremities. Some stiffness may occur, but contractures or deep vein thrombosis (DVT) would be more concerning immobility-related complications.

D. Difficulty hearing some types of sounds. Hearing loss is not a complication of immobility.

A. Absent B. Blowing sound due to restriction. C. A continuous medium pitched sound. D. High pitched, tinkling, rushing or growling.

Correct Answer is D

Explanation

A. Absent. Borborygmus refers to hyperactive bowel sounds, not absent sounds.

B. Blowing sound due to restriction. A blowing sound may indicate a vascular issue, such as a bruit over the aorta, rather than bowel motility.

C. A continuous medium-pitched sound. Medium-pitched sounds may be heard in normal bowel activity, but borborygmus refers to increased, hyperactive sounds.

D. High-pitched, tinkling, rushing, or growling. Borborygmus describes hyperactive bowel sounds, which occur in conditions such as gastroenteritis or hunger.

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A nurse is checking a school-age child for pediculosis capitis (head lice). Which of the following findings is a definitive indication of this condition?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An older adult client in a long-term care facility had a stroke 4 weeks ago and has been unable to move independently since that time. The nurse caring for her should observe for which of the following findings that indicates a complication of immobility?

Correct Answer is A

Explanation

When reviewing the medical record of a newly assigned client, the nurse notes borborygmus documented to describe bowel sounds on the previous abdominal assessment. The nurse knows this means that the client's bowel sounds were what?

Correct Answer is D

Explanation

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