Nokea
A client with no history of immunosuppressive disease has a Mantoux tuberculin skin test. The results indicate an area of induration that is 8 mm in size. How should the nurse interpret this result?
- A. Active tuberculosis
- B. A negative response
- C. A history of tuberculosis
- D. Past exposure to tuberculosis
Correct Answer: B
Rationale: Induration of 15 mm or more is considered positive for clients in low-risk groups. More than 5 mm of induration is considered a positive result for clients with known or suspected human immunodeficiency virus infection, persons with organ transplants, persons in close contact with a known case of tuberculosis, and those with a chest x-ray study suggestive of previous tuberculosis. More than 10 mm of induration is considered positive in all other high-risk groups, such as intravenous drug users.
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You measure your 5 year old client's vital signs as: • Respiratory rate: 32 breaths per minute • Pulse: 100 beats per minute • Blood pressure: 85/55. The mother asks you if these vital signs are normal. You should respond to this mother's question by stating:
- A. The respiratory rate is a little too fast but the other vital signs are normal.'
- B. The pulse rate is a little too fast but the other vital signs are normal.'
- C. The blood pressure is a little low but the other vital signs are normal.'
- D. All of these vital signs are normal for a child that is 2 years of age.'
Correct Answer: A
Rationale: For a 5-year-old, normal ranges are approximately: respiratory rate 20-25 breaths/min, pulse 70-115 beats/min, blood pressure ~90-110/55-65 mmHg. The respiratory rate (32) is slightly high, while the pulse and blood pressure are within normal limits.
You are a hospice nurse who, as part of your role, does follow up counseling and care for the significant others of deceased spouses for one year after their loss. Whose theory of grief and loss would you most likely integrate into your practice as you perform this role?
- A. Engel's theory
- B. Kubler Ross' theory
- C. Lewin's theory
- D. Warden's theory
Correct Answer: B
Rationale: Kubler-Ross' theory of the five stages of grief (denial, anger, bargaining, depression, acceptance) is widely used in hospice care to guide counseling for grieving significant others.
The nurse working in a long-term care setting attended a workshop on creating a restraint-free environment for the residents. When several coworkers firmly resist changing stating that their current methods are satisfactory, which action should aid the nurse in being effective in facilitating change?
- A. Pointing out to coworkers the various mistakes that they are presently making in adhering to outdated restraint procedures
- B. Informing the nursing supervisor that current restraint policies must be changed and requesting that all staff be required to comply
- C. Writing a new restraint policy over the weekend and distributing it to coworkers for immediate implementation on Monday morning
- D. Asking coworkers to help gather data comparing the facility's restraint procedures and outcomes with those of others using revised procedures
Correct Answer: D
Rationale: To be an effective change agent, the nurse must work collaboratively with others to solve common problems. The nurse who works collaboratively with others to facilitate change has a much greater chance of success than one who unilaterally demands or implements change. By enlisting the assistance of others, there is a greater chance that they will support proposed changes in procedures. To focus on errors (perceived or real) serves only to alienate others and is not effective in promoting change. A punitive atmosphere is not effective in promoting change because it discourages people from taking risks.
The membranes of a multigravid client in active labor rupture spontaneously, revealing greenish colored amniotic fluid. The nurse interprets this finding as related to which of the following?
- A. Passage of meconium by the fetus.
- B. Maternal intrauterine infection.
- C. Rh incompatibility between mother and fetus.
- D. Maternal sexually transmitted disease.
Correct Answer: A
Rationale: Greenish amniotic fluid indicates meconium passage, often due to fetal stress.
A 6-year-old child has had heart surgery to repair tetralogy of Fallot. When developing the discharge plan, the nurse should include information about:
- A. Allowing the child to lead a normal, active life.
- B. Persuading the child to get enough rest.
- C. Having the child develop postoperative complications.
- D. Having the child out of school for a month.
Correct Answer: A
Rationale: After tetralogy of Fallot repair, children can often lead a normal, active life with appropriate follow-up.