Nokea
A client visiting a family planning clinic is suspected of having an STD. The most diagnostic test for all stages of treponema pallidum (syphilis) is the:
- A. Venereal Disease Research Lab (VDRL)
- B. Rapid plasma reagin (RPR)
- C. Florescent treponemal antibody (FTA-Abs)
- D. Thayer-Martin culture (TMC)
Correct Answer: C
Rationale: The FTA-Abs test is the most specific and diagnostic for all stages of syphilis. VDRL and RPR are non-treponemal tests that can have false positives, so A and B are incorrect. Thayer-Martin culture is used for gonorrhea, so D is incorrect.
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A client with advanced Alzheimer’s dementia is admitted to a skilled nursing facility for delirium. The health care provider prescribes ambulation with partial weight bearing. Which would be the most appropriate method for the nurse to use to transfer this client safely?
- A. 1-person stand and pivot with a gait belt and walker
- B. 2-person full-body sling lift
- C. 2-person motorized standing-assist lift
- D. 2-person stand and pivot with a gait belt and walker
Correct Answer: D
Rationale: A 2-person stand and pivot with a gait belt and walker ensures safety for a client with dementia and partial weight bearing, accounting for confusion and weakness. One-person transfer risks falls, and lifts are excessive for ambulation.
At a community health fair the blood pressure of a 62 year-old client is 160/96. The client states 'My blood pressure is usually much lower.' The nurse should tell the client to
- A. go get a blood pressure check within the next 48 to 72 hours
- B. check blood pressure again in 2 months
- C. see the health care provider immediately
- D. visit the health care provider within 1 week for a BP check
Correct Answer: A
Rationale: The blood pressure reading is moderately high with the need to have it rechecked in a few days. Although the client states it is 'usually much lower,' a concern exists for complications such as stroke. An immediate check by the provider of care is not warranted. Waiting 2 months or a week for follow-up is too long.
Which incidence should be documented on an unusual incident report?
- A. The client leaves the hospital against the doctor's advice.
- B. The client develops a fever after receiving a blood transfusion.
- C. The client reports an upset stomach after taking an antibiotic.
- D. The client falls in her bathroom.
Correct Answer: D
Rationale: A fall is an unusual incident requiring documentation due to potential injury and liability. Leaving AMA, transfusion fever, or upset stomach are notable but less likely to require an incident report.
The nurse is reinforcing teaching to a client who is newly diagnosed with conversion disorder. The client begins crying and states, 'The health care provider must think I’m crazy because of my diagnosis.' What is the best response to the client?
- A. Conversion disorder is a diagnosis that acknowledges your symptoms are real, even if there isn’t a physical cause
- B. I am very sorry to hear this, but are you sure that’s what the provider meant? Maybe you misunderstood
- C. The health care provider is probably wrong. I’ll give you the information to contact my health care provider
- D. Why do you think you were diagnosed with conversion disorder?
Correct Answer: A
Rationale: Reassuring the client that conversion disorder validates real symptoms without a physical cause reduces stigma and clarifies the diagnosis. Other responses dismiss, question, or deflect the client’s concerns.
A home health nurse is caring for a client with a pressure sore that is red, with serous drainage, is 2 inches in diameter with loss of subcutaneous tissue. The appropriate dressing for this wound is
- A. Transparent film dressing
- B. Wet dressing with debridement granules
- C. Wet to dry with hydrogen peroxide
- D. Moist saline dressing
Correct Answer: D
Rationale: Moist saline dressing. A stage III pressure ulcer with granulation tissue requires a moist environment to promote healing.