Nokea
A client has a history of syphilis infection. The nurse interprets that the client has been re-infected when which characteristic is noted in a penile lesion?
- A. Papular areas and erythema
- B. Cauliflower-like appearance
- C. Induration and absence of pain
- D. Multiple vesicles, with some that have ruptured
Correct Answer: C
Rationale: The characteristic lesion of syphilis is painless and indurated. The lesion is referred to as a chancre. Scabies is characterized by erythematous, papular eruptions. Genital warts are characterized by cauliflower-like growths, or growths that are soft and fleshy. Genital herpes is accompanied by the presence of one or more vesicles that then rupture and heal.
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A Hispanic client is admitted to the surgical unit from the emergency department for an appendectomy. The nurse conducts the preoperative preparations and determines that the client has difficulty understanding English. The surgeon needs to obtain the client's informed consent. The nurse course for obtaining the client's informed consent is to:
- A. Have the client call a family member to act as interpreter
- B. Have the client sign the Spanish surgical consent form
- C. Call the Spanish interpreter to translate the surgeon's explanation of the procedure, risks, and alternatives to obtain the client's consent and to answer the client's questions
- D. Notify the surgical charge nurse of the situation
Correct Answer: C
Rationale: The surgeon is required to give the client explanations and have questions answered. The nurse has no way of assessing the client's understanding without the interpreter. The client should sign the Spanish consent form only after receiving an explanation of the procedure, its risks, and alternatives. A family member cannot be relied on to translate the surgeon's instructions accurately.
Which of the following is a commonality that is shared in terms of both restraints and urinary catheters?
- A. Both can lead to infection.
- B. Both are invasive procedures.
- C. Both are considered sentinel.
- D. Both are the last resort.
Correct Answer: A
Rationale: Both restraints and urinary catheters can lead to infections restraints via skin breakdown and catheters via urinary tract infections if not properly managed.
Which of the following impacts on the client's preferences in terms of hygiene routines and practices?
- A. Culture
- B. Locus of control
- C. Bodily surface area
- D. Diaphoresis
Correct Answer: A
Rationale: Culture significantly influences hygiene preferences, as beliefs and practices vary widely across cultural groups.
A client with type 2 diabetes is admitted with a blood glucose level of 450 mg/dL. The nurse should anticipate which of the following orders?
- A. Regular insulin IV
- B. Oral metformin
- C. Glucagon injection
- D. Potassium supplement
Correct Answer: A
Rationale: Hyperglycemia requires regular insulin IV to rapidly lower blood glucose. Metformin is oral and slower, glucagon raises glucose, and potassium is not indicated without further assessment.
The nurse is assessing a client with a suspected urinary tract infection. Which of the following symptoms is most likely to be present?
- A. Flank pain.
- B. Hypotension.
- C. Bradycardia.
- D. Dry skin.
Correct Answer: A
Rationale: Flank pain is a common symptom of a urinary tract infection, especially if it involves the kidneys.