Nokea
A client is upset because they just found out that they have syphilis. The client tells the nurse, 'This is so upsetting! Does everyone need to know?' Which of the following responses, if made by the nurse, is the most therapeutic?
- A. We need to report this diagnosis to the local public health department, and they will contact your past partners.
- B. According to the Health Insurance Portability and Accountability Act (HIPAA), I can't tell anyone without your permission.
- C. You really should contact your sexual partners so they can be treated too.
- D. I understand you're upset. I'll stay here with you so that you can talk about it.
Correct Answer: A
Rationale: Reporting syphilis to the public health department is required for contact tracing, and this response addresses the client's concern while explaining the process.
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The nurse has attended a staff education program about caring for clients with acute osteomyelitis. Which of the following statements by the nurse would indicate a correct understanding of the teaching?
- A. IV antibiotic therapy is typically given for seven to fourteen days.
- B. The most common cause of acute osteomyelitis is a virus.
- C. A significant fever is typically greater than 101°F (38.3°C).
- D. Petechiae on the affected extremity is a common finding.
Correct Answer: C
Rationale: A fever greater than 101°F is a common finding in acute osteomyelitis due to the inflammatory response.
The nurse is triaging a client who reports recent international travel. The primary healthcare provider (PHCP) suspects the client may have severe acute respiratory syndrome (SARS). The nurse should initially
- A. place the client on contact and airborne precautions.
- B. obtain blood, urine, and sputum for culture.
- C. prepare the client for a chest radiograph (x-ray).
- D. infuse 0.9 saline at 100mL/hr.
Correct Answer: A
Rationale: SARS requires contact and airborne precautions to prevent transmission due to its respiratory spread.
The nurse is counseling a female client newly diagnosed with herpes simplex virus in the genitals. Which symptoms should the nurse educate the client to expect before an outbreak? Select all that apply.
- A. Lymphadenopathy
- B. Vaginal discharge
- C. Paresthesia
- D. Dysmenorrhea
- E. Malaise
Correct Answer: A,C,E
Rationale: Lymphadenopathy, paresthesia, and malaise are prodromal symptoms of genital herpes outbreaks, indicating viral reactivation.
The nurse has just completed a continuing education lecture regarding the human immunodeficiency virus (HIV). Which of the following statements by the nurse indicate correct understanding? Select all that apply.
- A. I will clean contaminated surfaces with soap and hot water.
- B. The goal of treatment is for the client's viral load to increase and CD4 cells to decrease.
- C. Pre-exposure prophylaxis (PREP) is available to those with risk factors for HIV.
- D. Vertical transmission (mother to fetus) may be reduced with the use of antiretrovirals.
- E. It is possible to spread the infection through contaminated water.
Correct Answer: C,D
Rationale: Pre-exposure prophylaxis (PrEP) is effective for high-risk individuals, and antiretrovirals reduce vertical transmission. HIV is not spread through water, and the treatment goal is to decrease viral load and increase CD4 cells.
The nurse has attended a staff education program about indwelling urinary catheter-associated infections (CAUTI). Which nursing intervention is most effective in preventing a CAUTI in hospitalized clients?
- A. Implementing strict sterile technique during catheter insertion and maintenance.
- B. Using antibacterial indwelling urinary catheters for all clients requiring urinary catheterization.
- C. Limiting the duration of indwelling urinary catheter use and promptly removing them when no longer needed
- D. Administering prophylactic antibiotics to all clients with indwelling urinary catheters in place.
Correct Answer: C
Rationale: Limiting catheter duration is the most effective way to prevent CAUTI, as prolonged use increases infection risk.