Nurse caring for 19 yo client who is sexually active & has c...

Nurse caring for 19 yo client who is sexually active & has come to college health clinic for first time for checkup. Which intervention should nurse perform to determine client's health promotion & disease prevention?

A. Measure the vital signs
B. Encourage HIV screening
C. Determine client's risk factors
D. Instruct client to use condoms

Correct Answer: C

Rationale: The correct answer is C: Determine client's risk factors. This intervention is essential to assess the client's current health status, identify potential health risks, and develop a personalized health promotion plan. By understanding the client's risk factors, the nurse can provide targeted education and interventions to prevent diseases and promote overall well-being.

A: Measuring vital signs is important but does not directly address health promotion and disease prevention specific to the client's sexual activity.
B: Encouraging HIV screening is important, but it focuses on a specific disease rather than a comprehensive assessment of risk factors.
D: Instructing the client to use condoms is important for safe sex practices but does not address broader health promotion and disease prevention strategies effectively.

By 2nd post-op day, a client has not achieved satisfactory pain relief. Based on this evaluation, what should nurse do next according to nursing process?

A. Reassess client to determine reasons for unsatisfactory pain relief
B. See whether pain lessens during next 24h
C. Change plan to ensure client achieves adequate pain relief
D. Teach client about plan of care for managing his pain

Correct Answer: A

Rationale: The correct answer is A. In the nursing process, the first step in addressing a client's unsatisfactory pain relief is to reassess the client to determine the reasons for it. This involves evaluating the pain intensity, location, characteristics, aggravating factors, and the client's response to current pain management interventions. By reassessing, the nurse can identify any underlying causes contributing to the lack of pain relief and adjust the plan of care accordingly.

Choice B is incorrect because waiting another 24 hours without further assessment delays appropriate intervention. Choice C is incorrect as changing the plan without reassessment may not address the root cause of the issue. Choice D is incorrect as teaching the client about the plan of care should come after reassessment to ensure it is tailored to the client's specific needs.

Nursing instructor is explaining various stages of lifespan to students. Nurse should offer which of following behaviors by young adult as example of accomplishing Erikson's tasks for psychosocial development during middle adulthood?

A. "client evaluates his behavior after social interaction"
B. client states he is learning to trust others
C. client wishes to find meaningful relationships
D. client expresses concerns about next generation

Correct Answer: D

Rationale: The correct answer is D because expressing concerns about the next generation aligns with Erikson's task of generativity vs. stagnation during middle adulthood. This stage involves contributing to the well-being of future generations. Choice A focuses on self-reflection, not generativity. Choice B refers to Erikson's trust vs. mistrust stage in infancy. Choice C relates to forming intimate relationships in young adulthood. This highlights the importance of understanding Erikson's psychosocial stages to identify appropriate behaviors.

Nurse is talking with 45 yo client with no specific family hx of cancer or DM, about planning routine screenings. Which client statement indicates client understands how to proceed?

A. So I don't need colon cancer procedure for another 2-3 yrs
B. For now, I should continue to have mammogram each year
C. Because doctor just did pap smear, I'll come back next year for another
D. I had my blood glucose test last year so I won't need it again till next year

Correct Answer: B

Rationale: The correct answer is B: "For now, I should continue to have a mammogram each year." This response shows understanding of the need for annual mammograms for breast cancer screening, which is recommended for women aged 45 and older. The other choices are incorrect because: A suggests delaying colon cancer screening, which is typically recommended starting at age 50; C implies annual pap smears, which are usually done every 3-5 years depending on age and risk factors; D indicates a lack of understanding about the frequency of blood glucose testing for diabetes screening.

Nurse is reviewing hand hygiene techniques with a group of APs. Which instructions should the nurse include when discussing handwashing? (Select all that apply.)

A. Apply 3-5 mL of liquid soap to dry hands
B. Wash hands with soap & water for at least 15 seconds
C. Rinse hands with hot water
D. Use a clean paper towel to turn off hand faucets
E. Allow hands to air dry after washing

Correct Answer: B,D

Rationale: Correct Answer: B, D

Rationale:
B: Washing hands with soap & water for at least 15 seconds is crucial to ensure thorough cleaning and removal of germs.
D: Using a clean paper towel to turn off hand faucets helps prevent recontamination of clean hands.

Incorrect Choices:
A: Applying 3-5 mL of liquid soap to dry hands is not specified in handwashing guidelines.
C: Rinsing hands with hot water can strip the skin of natural oils and may not be necessary for effective hand hygiene.
E: Allowing hands to air dry after washing may not be sufficient to eliminate germs and is not a recommended step in hand hygiene protocols.

Nurse providing discharge instructions to client with prescription for oxygen use in home. Which should nurse teach about using oxygen safely in his home? (Select all that apply.)

A. Family members who smoke must be at least 10 ft from client when his oxygen is on
B. Nail polish shouldn't be used near client receiving oxygen
C. A 'No Smoking' sign should be placed on front door
D. Cotton bedding/clothing should be replaced with items made from wool
E. Fire extinguisher should be readily available in home

Correct Answer: B,C,E

Rationale: Correct Answer: B, C, E

Rationale:
B: Nail polish contains flammable substances, which can pose a fire hazard near oxygen. Teaching the client to avoid using nail polish near oxygen is essential for safety.
C: Placing a 'No Smoking' sign on the front door serves as a clear reminder to visitors and family members about the importance of not smoking near the client using oxygen.
E: Having a fire extinguisher readily available in the home is crucial in case of a fire emergency, especially when oxygen is being used, as oxygen can accelerate combustion.

Incorrect Choices:
A: While it is important for family members who smoke to stay away from the client when oxygen is on, the 10 ft rule is arbitrary and not evidence-based.
D: There is no significant safety benefit in replacing cotton bedding/clothing with items made from wool regarding oxygen use in the home.
Summary: Teaching about avoiding flammable substances like nail polish, displaying a 'No Smoking' sign,