Nokea
A client is in her third month of her first pregnancy. During the interview, she tells the nurse that she has several sex partners and is unsure of the identity of the baby's father. Which of the following nursing interventions is a priority?
- A. Counsel the woman to consent to HIV screening
- B. Perform tests for sexually transmitted diseases
- C. Discuss her high risk for cervical cancer
- D. Refer the client to a family planning clinic
Correct Answer: A
Rationale: Counsel the woman to consent to HIV screening. The client's behavior places her at high risk for HIV. Testing is the first step in identifying and managing the risk of HIV infection. Early detection allows for timely interventions and better outcomes. While performing tests for sexually transmitted diseases (choice B) is important, addressing the immediate and potentially life-threatening risk of HIV takes precedence. Discussing the risk for cervical cancer (choice C) is not the priority at this time as HIV screening is more urgent. Referring the client to a family planning clinic (choice D) is not the immediate priority given the client's current high-risk behavior and the need to address the immediate threat of HIV infection.
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A patient presents with vesicles covering the upper torso. Which of the following situations could cause this condition?
- A. Knife fight
- B. Auto accident
- C. Sunburn
- D. Fungal infection
Correct Answer: C
Rationale: Vesicles are fluid-filled blisters. In the context of the upper torso, the presentation of vesicles suggests a second-degree sunburn. Sunburn can cause blistering, leading to the formation of vesicles. Choice A, 'Knife fight,' does not align with the presentation of vesicles on the upper torso due to trauma. Choice B, 'Auto accident,' is more likely to cause abrasions or bruises rather than vesicles. Choice D, 'Fungal infection,' typically presents with other symptoms such as redness, itching, or scaling, but not vesicles on the upper torso.
Which of these individuals would the nurse suspect as having the greatest risk of contracting Hepatitis B?
- A. A sexually active 45-year-old man who has Type 1 Diabetes
- B. A 75-year-old woman who lives in a crowded nursing home
- C. A child who lives in a country with poor sanitation and hygiene standards
- D. A sexually active 23-year-old man who works in a hospital
Correct Answer: D
Rationale: The correct answer is a sexually active 23-year-old man who works in a hospital. This individual is at the highest risk of contracting Hepatitis B due to exposure in a healthcare setting where potential bloodborne pathogens are present. Being sexually active also increases the risk of transmission through sexual contact. Choice A, a 45-year-old man with Type 1 Diabetes, is not directly associated with an increased risk of Hepatitis B. Choice B, a 75-year-old woman living in a crowded nursing home, is at risk for other infections due to the living environment but not specifically for Hepatitis B. Choice C, a child in a country with poor sanitation, is more at risk for water or foodborne illnesses rather than Hepatitis B transmission.
The physician has decided to perform a thoracentesis based on Mr. R's assessment. Which of the following actions from the nurse is most appropriate?
- A. Instruct the client not to talk during the procedure
- B. Assist the client to sit upright or slightly lean forward
- C. Insert a 20-gauge needle just above the 4th intercostal space
- D. Connect the needle to suction to remove fluid that has collected in the pleural space
Correct Answer: A
Rationale: The correct answer is to instruct the client not to talk during the procedure. This is important to prevent air from being drawn into the pleural space during the thoracentesis. Choice B is incorrect because the client should be sitting upright or slightly leaning forward during the procedure to facilitate access to the pleural space. Choice C is incorrect as the nurse should not perform the thoracentesis procedure, which involves inserting a needle into the pleural space - this is the physician's responsibility. Choice D is incorrect as connecting the needle to suction to remove fluid is not the appropriate procedure for a thoracentesis. Thoracentesis is typically done to remove fluid or air for diagnostic or therapeutic purposes, not to connect to suction to remove fluid that has collected in the pleural space.
How does shock typically progress?
- A. Compensated to hypotensive shock in hours and hypotensive shock to cardiac arrest in minutes
- B. Compensated to hypotensive shock in minutes and hypotensive shock to cardiac arrest in hours
- C. Hypotensive to compensated shock in hours and compensated shock to cardiac arrest in minutes
- D. Hypotensive to compensated shock in minutes and compensated shock to cardiac arrest in hours
Correct Answer: A
Rationale: Shock typically progresses from a compensated state to hypotensive shock over a period of hours. In the compensated phase, the body is trying to maintain perfusion. It is crucial to identify and intervene during this phase to prevent progression to hypotensive shock, where blood pressure drops significantly. If not promptly managed, hypotensive shock can rapidly deteriorate into cardiac arrest in minutes due to inadequate perfusion to vital organs. Choices B, C, and D are incorrect as they do not follow the typical progression of shock stages as seen in clinical practice. Understanding the stages of shock and their timeframes is crucial for early recognition and appropriate intervention to prevent further deterioration.
The clinic nurse is obtaining data about a child with a diagnosis of lactose intolerance. Which data should the nurse expect to obtain on assessment?
- A. Reports of frothy stools and diarrhea
- B. Reports of foul-smelling ribbon stools
- C. Reports of profuse, watery diarrhea and vomiting
- D. Reports of diffuse abdominal pain unrelated to meals or activity
Correct Answer: A
Rationale: Lactose intolerance commonly presents with frothy stools and diarrhea due to the inability to digest lactose. Other symptoms include abdominal distension, crampy abdominal pain, and excessive flatus. Foul-smelling ribbon stools are indicative of Hirschsprung's disease, not lactose intolerance. Profuse, watery diarrhea and vomiting are more characteristic of celiac disease. Diffuse abdominal pain unrelated to meals or activity is a typical symptom of irritable bowel syndrome, not lactose intolerance.