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A client with human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome confides that he is homosexual and his employer does not know his HIV status. Which response by the nurse is best?
- A. Would you like me to help you tell them?
- B. The information you confide in me is confidential.
- C. I must share this information with your family.
- D. I must share this information with your employer.
Correct Answer: B
Rationale: The nurse is responsible for maintaining confidentiality of this disclosure by the client. Sharing personal health information without consent violates patient privacy laws, such as HIPAA, except in specific circumstances like public health reporting. Offering to help disclose or sharing with family or employer without consent is inappropriate.
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Identify this cardiac rhythm strip. Fill in the blank. A. Third Degree Heart Block B. Second-Degree Atrioventricular Block, Type II C. Ventricular fibrillation D. Premature Atrial Contractions
- B. Third Degree Heart Block
- C. Second-Degree Atrioventricular Block, Type II
- D. Ventricular fibrillation
- E. Premature Atrial Contractions
Correct Answer: A
Rationale: Third Degree Heart Block shows complete dissociation between P waves and QRS complexes, assuming the strip matches this description.
Which oral contraceptive is considered safe for use while breast-feeding because it will not affect the breast milk or breast-feeding?
- A. Estrogen.
- B. Estrogen and progestin.
- C. Progestin.
- D. Testosterone.
Correct Answer: C
Rationale: Progestin-only contraceptives are safe during breast-feeding, as they do not affect milk production.
A client with Parkinson's disease is prescribed levodopa-carbidopa. Which side effect should the nurse monitor for?
- A. Hypertension.
- B. Dyskinesia.
- C. Hypoglycemia.
- D. Weight gain.
Correct Answer: B
Rationale: Dyskinesia, involuntary movements, is a common side effect of levodopa-carbidopa due to dopamine overstimulation.
The nurse should tell a client who is scheduled for a bone marrow biopsy that the specimen can be withdrawn from which site?
- A. Ribs
- B. Femur
- C. Scapula
- D. Sternum
Correct Answer: D
Rationale: The most common sites for bone marrow biopsy in the adult are the iliac crest and the sternum. These areas are rich in bone marrow and are easily accessible for testing. The femur, scapula, and ribs are not sites for bone marrow biopsy.
The nurse should instruct the parent of a child who is taking valproic acid (Depakene) that the child will need to have routine blood analyses consisting of which of the following?
- A. Complete blood count (CBC) and alkaline phosphate level.
- B. Amylase and platelet levels.
- C. Electrolytes and CBC.
- D. Platelet and fibrinogen levels.
Correct Answer: B
Rationale: Valproic acid requires monitoring of amylase (for pancreatitis) and platelet levels (for thrombocytopenia).