Nokea
A client with AIDS asks the nurse why he cannot have a pitcher of water left at his bedside. The nurse should tell the client that:
- A. It would be best for him to drink ice water.
- B. He should drink several glasses of juice instead.
- C. It makes it easier to keep a record of his intake.
- D. He should drink only freshly run water.
Correct Answer: D
Rationale: For clients with AIDS, stagnant water in a pitcher can harbor bacteria, posing an infection risk due to their compromised immune system. Freshly run water minimizes this risk.
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The nurse is caring for a client with a diagnosis of major depressive disorder. Which of the following client statements would indicate that the client is responding positively to the prescribed antidepressant therapy?
- A. I feel like my energy level is starting to improve.
- B. I still don’t enjoy doing things I used to love.
- C. I have trouble sleeping through the night.
- D. I feel worthless and don’t want to see anyone.
Correct Answer: A
Rationale: improved energy level is a positive sign of response to antidepressant therapy
A teenage client tells the nurse about her plans to be a lifeguard this summer. The nurse would be concerned if she saw the client was taking which medication? Select all that apply.
- A. tetrahydrozoline (Tetryzoline)
- B. isotretinoin (Accutane)
- C. levonorgestrel (Levora)
- D. sulfamethoxazole (Bactrim)
Correct Answer: B
Rationale: Isotretinoin (Accutane) causes photosensitivity, increasing sunburn risk, which is concerning for a lifeguard exposed to sunlight. Other medications do not pose significant outdoor risks.
The nurse is preparing to admit a client from the emergency department with tuberculosis. Which of the following should the nurse anticipate in caring for this client? Select all that apply.
- A. fall precautions
- B. droplet precautions
- C. airborne precautions
- D. standard precautions
- E. placement in a negative airflow room
- F. use of PPE, including an N95 mask or powered air purifying respirators (PAPRs)
Correct Answer: C, D, E, F
Rationale: Tuberculosis requires airborne precautions, standard precautions, negative airflow rooms, and N95/PAPR use due to respiratory transmission. Fall precautions are not specific, and droplet precautions are incorrect.
The client with a cervical fracture is placed in traction. Which type of traction will be utilized at the time of discharge?
- A. Russell's traction
- B. Buck's traction
- C. Halo traction
- D. Crutchfield tong traction
Correct Answer: C
Rationale: Halo traction is used for cervical fractures and can be maintained post-discharge for stabilization.
The nurse is caring for a client with a diagnosis of hepatitis who is experiencing pruritis. Which would be the most appropriate nursing intervention?
- A. Suggest that the client take warm showers two times per day
- B. Add baby oil to the client's bath water
- C. Apply powder to the client's skin
- D. Suggest a hot-water rinse after bathing
Correct Answer: B
Rationale: Adding baby oil to bath water helps moisturize the skin and alleviate pruritis caused by hepatitis, as it soothes dry, itchy skin without causing irritation.