Nokea
A 19-year-old college student has a Mantoux test performed at the college health clinic. The result is positive. The clinic nurse should
- A. refer the student to an appropriate center for further testing.
- B. restrict the student's activity until his parents can be notified.
- C. notify the local Public Health Department.
- D. place the student in an isolation room in the college infirmary.
Correct Answer: A
Rationale: will perform chest x-ray
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The mother of a seven-year-old child is dying.
The nurse should anticipate that the seven-year-old child would have which of the following concepts of death?
- A. Death is punishment for his/her actions.
- B. Death is inevitable and irreversible.
- C. Death is temporary and gradual.
- D. Death as a concept based on past experience.
Correct Answer: A
Rationale: Strategy: Remember growth and development. (1) correct-seven-year-olds see death as a punishment (2) by age of 9, most children begin to develop an adult concept of death and begin to understand that death is irreversible (3) is a preschool child's concept of death (4) is an adolescent's concept of death
The nurse would identify which of the following clients as being at the highest risk for developing a pulmonary embolus?
- A. A 19-year-old four days postpartum with an obstetrical history of placenta previa.
- B. An obese 40-year-old man with multiple pelvic fractures from an auto accident two days ago.
- C. A 65-year-old woman who had a fractured hip repaired 10 days ago and who is in physical therapy daily.
- D. A 22-year-old leukemic client with a platelet count of 120,000/mm³ and a hemoglobin level of 9.0 g.
Correct Answer: B
Rationale: obesity, immobility, and pooling of blood in the pelvic cavity contribute to development of pulmonary emboli
A client has come to the clinic for a hepatitis B vaccine and asks if he has to be re-vaccinated after his first injection. Which of the following responses by the nurse is BEST?
- A. A booster shot is required yearly.
- B. Additional injections are given at one and six months.
- C. Repeat doses are given at two and four months.
- D. Revaccination is not required.
Correct Answer: B
Rationale: hepatitis B vaccine is repeated at one and six months
A middle-aged adult is seen in the emergency room for complaints of severe right-flank pain. The client is twenty pounds overweight, lives a sedentary lifestyle, and was treated for renal calculi four years ago. Which of the following actions, if performed by the nurse, is MOST important?
- A. Ensure that the client has nothing to eat or drink.
- B. Obtain a 'clean-catch' urine specimen for analysis.
- C. Provide warm packs to relieve discomfort.
- D. Measure and strain the client's urine.
Correct Answer: D
Rationale: will document passage of stone and allow composition to be analyzed
A young child is placed on droplet precautions. The nurse is caring for which of the following clients?
- A. A child with cystic fibrosis.
- B. A child with tonsillitis.
- C. A child with bronchitis.
- D. A child with pertussis.
Correct Answer: D
Rationale: droplet precautions required, private room, maintain spatial separation of 3 feet between patient and visitors