Nokea
A 19-year-old female comes into the women's clinic for an STD test. The nurse explains all of the following confirmed cases of STDs must be reported to the Centers for Disease Control (CDC) EXCEPT
- A. genital herpes.
- B. chlamydia.
- C. hepatitis B.
- D. gonorrhea.
Correct Answer: A
Rationale: Chlamydia, gonorrhea, and hepatitis B are reportable to the CDC. Genital herpes is not nationally reportable, though local regulations may vary.
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A client with a history of seizures is prescribed phenytoin (Dilantin) 100 mg three times daily. The nurse should instruct the client to report which of the following side effects to the physician?
- A. Mild nausea after taking the medication.
- B. Gingival hyperplasia and rash.
- C. Slight drowsiness in the morning.
- D. Increased appetite and weight gain.
Correct Answer: B
Rationale: gingival hyperplasia and rash are significant side effects of phenytoin that require medical attention
A critically injured woman is rushed to the ER. She needs an immediate blood transfusion, and there is no time to crossmatch blood type. The nurse anticipates the physician will call for
- A. 1 unit of AB positive blood.
- B. 1 unit of O positive blood.
- C. 1 unit of AB negative blood.
- D. 1 unit of O negative blood.
Correct Answer: D
Rationale: O negative blood is the universal donor, safe for emergency transfusions without crossmatching, minimizing reaction risk.
The nurse is caring for a client with rheumatoid arthritis. The nurse knows that the client's symptoms will be most improved by:
- A. Taking a warm shower upon awakening
- B. Applying ice packs to the joints
- C. Taking two aspirin before going to bed
- D. Going for an early morning walk
Correct Answer: A
Rationale: A warm shower reduces morning stiffness in rheumatoid arthritis by improving joint mobility and reducing inflammation.
A client being treated with sodium warfarin (Coumadin) has a Protime of 120 seconds. Which intervention would be most important to include in the nursing care plan?
- A. Assess for signs of abnormal bleeding
- B. Anticipate an increase in the Coumadin dosage
- C. Instruct the client regarding the drug therapy
- D. Increase the frequency of neurological assessments
Correct Answer: A
Rationale: A Protime of 120 seconds indicates excessive anticoagulation, increasing the risk of bleeding, so assessing for abnormal bleeding is the most important intervention.
During a unit card game, a client with acute mania begins to sing loudly as she starts to undress. The nurse should:
- A. Ignore the client's behavior
- B. Exchange the cards for a checker board
- C. Send the other clients to their rooms
- D. Cover the client and walk her to her room
Correct Answer: D
Rationale: Covering the client and escorting her to a private area maintains dignity and safety, addressing the inappropriate behavior calmly.