Nokea
The nurse is planning care for a family whose children did not receive childhood immunizations. After one of the children contracted mumps, the father is diagnosed with orchitis. Which intervention should be included in the father's plan of care?
- A. Use of bedrest with scrotal support
- B. Administration of antibiotics for 10 days
- C. Applying heat to promote the healing process
- D. Using an ice pack to reduce scrotal pain
Correct Answer: A
Rationale: For orchitis, the recommended intervention is bedrest with scrotal support. This helps reduce swelling and discomfort in the scrotum. Antibiotics are generally not required for viral orchitis, so administering antibiotics for 10 days (Choice B) is not indicated. Applying heat (Choice C) may worsen swelling and should be avoided. Using an ice pack (Choice D) is not the preferred method for managing orchitis; it may not be as effective as providing support and rest for the scrotum.
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An adult client presents to the clinic with large draining ulcers on both lower legs that are characteristic of Kaposi's Sarcoma lesions. The client is accompanied by two family members. What action should the nurse take?
- A. Obtain a blood sample to determine if the client is HIV positive
- B. Send the family to the waiting area while conducting a head-to-toe assessment
- C. Complete a head-to-toe assessment to identify other signs of HIV
- D. Ask the family members to wear gloves when touching the client
Correct Answer: C
Rationale: In this scenario, the most appropriate action for the nurse to take is to complete a head-to-toe assessment to identify other signs of HIV. Kaposi's Sarcoma is commonly associated with HIV infection, and conducting a comprehensive assessment can provide crucial information on potential signs and symptoms related to HIV. This information is essential for providing appropriate care and treatment. Option A is not the priority at this moment, as the focus should be on assessing the client comprehensively first. Sending the family members away (Option B) may not be necessary if they are not interfering with the assessment process. While infection control is important, asking the family members to wear gloves (Option D) is not the most critical action to take in this situation.
When gathering subjective data from a client, what intervention should the nurse implement first?
- A. Listen attentively
- B. Establish rapport
- C. List problems
- D. Clarify inferences
Correct Answer: B
Rationale: Establishing rapport is the initial step the nurse should take when gathering subjective data from a client. Building trust and a good relationship with the client creates an environment where the client feels comfortable sharing accurate and honest information. Listening attentively is important but should come after rapport is established to enhance active listening. Listing problems and clarifying inferences are actions that occur later in the assessment process, after the nurse has established a good rapport and obtained a comprehensive understanding of the client's perspective. Therefore, option B is the correct answer.
Which situation is a violation of client confidentiality, as described in the Health Insurance Portability and Accountability Act (HIPAA)?
- A. A sign-in sheet kept at the front desk listing clients' last names and the time of their arrival
- B. A nurse's handwritten notes from a telephone report discarded in the office wastebasket
- C. A computer monitor screen located at the nurse's station in a high-traffic area
- D. Privileged Health Information (PHI) given to an ambulance driver for the transfer of a client
Correct Answer: C
Rationale: Choice C is a violation of client confidentiality as it exposes patient information to unauthorized individuals due to its location in a high-traffic area. HIPAA regulations require that electronic protected health information (ePHI) be safeguarded against unauthorized access, making the situation described in choice C a violation. Choices A, B, and D do not directly involve the exposure of patient information to unauthorized individuals. While choices A and B may pose some risks, they are not as severe as the direct exposure described in choice C. Choice D involves sharing information with an ambulance driver for a legitimate purpose, which does not violate HIPAA if done securely and in compliance with regulations.
The healthcare provider prescribes potassium chloride 25 mEq in 500 ml D5W to infuse over 6 hours. The available 20 ml vial of potassium chloride is labeled '10 mEq/5 ml.' How many ml of potassium chloride should the nurse add to the IV fluid?
- A. 12.5
- B. 5
- C. 10
- D. 20
Correct Answer: B
Rationale: To prepare 25 mEq of potassium chloride for the infusion, the nurse should add 5 ml of the 10 mEq/5 ml solution. This concentration provides the required amount of potassium chloride without exceeding the needed volume. Choice A would result in 12.5 mEq, which exceeds the prescribed amount. Choices C and D are incorrect as they do not align with the correct calculation based on the vial concentration.
Several months after a foot injury, an adult woman is diagnosed with neuropathic pain. The client describes the pain as severe and burning and is unable to put weight on her foot. She asks the nurse when the pain will 'finally go away.' How should the nurse respond?
- A. Explain that healing from the injury can take many months.
- B. Assist the client in developing a goal of managing the pain.
- C. Encourage the client to verbalize her fears about the pain.
- D. Complete an assessment of the client's functional ability.
Correct Answer: B
Rationale: The correct answer is B: 'Assist the client in developing a goal of managing the pain.' In cases of chronic neuropathic pain, complete resolution is often not achievable. Therefore, the most appropriate approach is to help the client develop strategies to manage the pain effectively. Choice A is incorrect because it may give false hope of immediate resolution, which is unlikely with neuropathic pain. Choice C is incorrect as it does not directly address the client's need for pain management. Choice D is incorrect as it focuses on functional ability assessment, which is not the priority when addressing the client's pain concerns.