Nokea
A healthcare professional is admitting a client who has tuberculosis. Which of the following types of transmission precautions should the healthcare professional plan to initiate?
- A. Contact
- B. Droplet
- C. Airborne
- D. Protective environment
Correct Answer: C
Rationale: Tuberculosis is transmitted through airborne particles, so airborne precautions are necessary to prevent the spread of the disease. Airborne precautions (Choice C) involve measures such as negative pressure rooms and N95 respirators to prevent the transmission of infectious agents that remain infectious over long distances when suspended in the air. Contact precautions (Choice A) are used for diseases that spread through direct contact with the patient or their environment. Droplet precautions (Choice B) are for diseases transmitted through respiratory droplets, typically over short distances. Protective environment (Choice D) is used for clients who are immunocompromised to protect them from environmental pathogens, not for diseases like tuberculosis that spread through the air.
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When interviewing the parents of a child with asthma, what information about the child's environment should be gathered most importantly?
- A. Household pets
- B. New furniture
- C. Lead-based paint
- D. Plants such as cactus
Correct Answer: A
Rationale: When assessing a child with asthma, it is crucial to gather information about potential triggers in their environment. Household pets, such as cats or dogs, are common triggers for asthma attacks due to pet dander and saliva. This information is essential to identify if exposure to pets at home could be exacerbating the child's asthma symptoms. Choices B, C, and D are less relevant in the context of asthma triggers. New furniture, lead-based paint, and plants like cactus are not typically primary triggers for asthma attacks compared to common allergens like pet dander.
A client with a history of deep vein thrombosis (DVT) is admitted with swelling and pain in the left leg. What is the most appropriate action for the LPN/LVN to take?
- A. Apply warm compresses to the affected leg.
- B. Elevate the left leg above the level of the heart.
- C. Measure the circumference of the left leg.
- D. Administer pain medication as prescribed.
Correct Answer: C
Rationale: Measuring the circumference of the left leg is the most appropriate action for an LPN/LVN when assessing a client with a history of DVT and presenting with swelling and pain in the left leg. This measurement helps to assess the extent of swelling objectively and monitor changes in the client's condition. Applying warm compresses (Choice A) may worsen the condition by potentially promoting clot development. Elevating the left leg above the level of the heart (Choice B) is generally recommended for DVT to improve venous return, but measuring the circumference is more appropriate in this scenario. Administering pain medication (Choice D) does not address the underlying issue and should not be the initial action taken.
Which assessment data reflects the need for nurses to include the problem, "Risk for falls," in a client's plan of care?
- A. Recent serum hemoglobin level of 16 g/dL
- B. Opioid analgesic received one hour ago
- C. Stooped posture with an unsteady gait
- D. Expressed feelings of depression
Correct Answer: B
Rationale: The correct answer is B. The recent administration of opioid analgesics increases the risk for falls due to potential side effects such as sedation and dizziness. Choice A, a recent serum hemoglobin level of 16 g/dL, is not directly related to the risk for falls. Choice C, stooped posture with an unsteady gait, may indicate an existing risk but does not directly reflect the need to include 'Risk for falls' in the care plan. Choice D, expressed feelings of depression, is important to address but is not directly associated with the risk for falls.
A client is expressing anger about his diagnosis of colorectal cancer. Which of the following actions should the nurse take?
- A. Reassure the client that this is an expected response to grief.
- B. Ignore the client's anger and continue with the plan of care.
- C. Tell the client that anger is not going to help his situation.
- D. Encourage the client to express his anger.
Correct Answer: A
Rationale: When a client is expressing anger about a diagnosis, it is essential for the nurse to validate the client's feelings. Choice A is correct because reassuring the client that anger is an expected response to grief acknowledges the client's emotions and encourages expression, fostering a therapeutic relationship. This validation helps the client feel understood and supported during a challenging time. Choice B is incorrect as ignoring the client's anger can lead to feelings of neglect and hinder effective communication, which is crucial for providing holistic care. Choice C is inappropriate because telling the client that anger is not helpful dismisses the client's emotions and can further escalate the situation, potentially damaging the nurse-client relationship. Choice D is not the best option as it does not involve acknowledging the client's feelings or providing support and validation, which are vital in promoting emotional well-being and trust between the client and the nurse.
The nurse is teaching the parents of a child who has head lice (pediculosis capitis). Which information will the nurse include in the teaching session?
- A. Treatment involves using regular shampoo.
- B. Products containing lindane are not recommended.
- C. Head lice may spread to furniture and other people.
- D. Manual removal is essential in treatment.
Correct Answer: C
Rationale: The correct answer is C. Head lice are highly contagious and can spread to furniture and other people if not treated promptly. Informing the parents about the potential spread of head lice emphasizes the importance of thorough treatment and prevention measures. Choice A is incorrect as regular shampoo is not typically effective in treating head lice. Choice B is incorrect as products containing lindane are not recommended due to safety concerns. Choice D is incorrect as manual removal, though labor-intensive, is a crucial step in effectively treating head lice infestations, but it is not the most pertinent information to include in the teaching session.