Nokea
A 16 y.o. girl is diagnosed with genital herpes. She is tearful and as she asks what she can do to prevent complications of the disease. Based on the data provided, which nursing diagnosis is appropriate for her plan of care?
- A. Risk for transmission of infection
- B. Pain
- C. Health-seeking behaviours
- D. Ineffective sexuality pattern
Correct Answer: A
Rationale: The correct answer is A: Risk for transmission of infection. This is appropriate because the girl has genital herpes, which is a sexually transmitted infection (STI) that can be transmitted to others through sexual contact. Therefore, the main concern is preventing the spread of the infection to others. Pain (B) is a symptom of herpes but not the primary concern here. Health-seeking behaviors (C) may be relevant for education and prevention, but not the immediate focus. Ineffective sexuality pattern (D) is not directly related to the risk of transmission of infection in this case.
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Which iron-rich foods should the nurse encourage an anemic client requiring iron therapy to eat?
- A. Shrimp and tomatoes
- B. Cheese and bananas
- C. Lobster and squash
- D. Lamb and peaches
Correct Answer: A
Rationale: The correct answer is A: Shrimp and tomatoes. Shrimp is a good source of heme iron, which is more easily absorbed by the body compared to non-heme iron found in plant-based foods. Tomatoes are rich in Vitamin C, which helps enhance iron absorption. Cheese, bananas, lobster, squash, lamb, and peaches do not provide significant amounts of iron essential for an anemic client. The combination of shrimp and tomatoes offers a balanced approach to increase iron levels effectively.
Mr. Go had a post-kidney transplant. What should the nurse immediately assess?
- A. fluid and electrolyte imbalances
- B. hepatotoxicity
- C. infection
- D. respiratory complications
Correct Answer: A
Rationale: The correct answer is A because post-kidney transplant patients are at high risk for fluid and electrolyte imbalances due to the impact of the surgery on renal function. The nurse should assess for signs of fluid overload or depletion and monitor electrolyte levels closely. Choice B, hepatotoxicity, is less immediate and not directly related to kidney transplant. Choice C, infection, is important but not the immediate priority. Choice D, respiratory complications, are also significant but not the most immediate concern post-kidney transplant.
Which of the following are examples of common factors in a client that may influence assessment priorities?
- A. Diet and exercise program
- B. Standing in the community
- C. Ability to pay for services
- D. Developmental stage
Correct Answer: A
Rationale: The correct answer is A: Diet and exercise program. This is because a client's diet and exercise program directly impact their physical health and well-being, making it an important factor to consider when determining assessment priorities. Understanding their dietary habits and level of physical activity can help identify potential health risks or areas for improvement.
Choices B, C, and D are incorrect because they do not directly relate to the client's physical health and well-being, which are crucial factors in determining assessment priorities. Standing in the community (B) may influence social interactions but does not necessarily impact assessment priorities. Ability to pay for services (C) relates to financial considerations rather than health assessment priorities. Developmental stage (D) may be important for understanding the client's cognitive and emotional development, but it is not as directly relevant to assessment priorities as diet and exercise.
Antihistamines are used cautiously in older men with prostatic hypertrophy for which of the ff reasons?
- A. Because the clients may experience increased drowsiness
- B. Because these clients may experience difficulty voiding
- C. Because these clients face a greater risk of cardiac arrest
- D. Because these clients have a lower autoimmune response CARING FOR CLIENTS WITH AIDS
Correct Answer: B
Rationale: The correct answer is B: Because these clients may experience difficulty voiding. Antihistamines can worsen urinary symptoms in men with prostatic hypertrophy by causing urinary retention. This is due to the anticholinergic effects of antihistamines, which can lead to decreased bladder contraction and difficulty in voiding. Increased drowsiness (choice A) is a common side effect of antihistamines but is not specific to older men with prostatic hypertrophy. Choice C, greater risk of cardiac arrest, is not directly related to the use of antihistamines in older men with prostatic hypertrophy. Choice D, lower autoimmune response in clients with AIDS, is unrelated to the use of antihistamines in older men with prostatic hypertrophy.
The nurse will assess a loss of ability in which of the following areas?
- A. Balance
- B. Speech
- C. Judgment
- D. Endurance
Correct Answer: A
Rationale: The correct answer is A: Balance. Loss of ability in balance can indicate various health issues like neurological disorders or musculoskeletal problems. The nurse can assess this by observing the patient's gait, balance while standing, and coordination. Speech (B) relates to communication abilities, judgment (C) involves decision-making skills, and endurance (D) is related to stamina and physical capacity, which are not directly linked to loss of ability.