Nokea
A college student goes to the college clinic and asks the best way to avoid contracting an STD. The nurse provides the clinic’s standard STD teaching. Which statement by the student indicates the need for additional instruction?
- A. “There is no guarantee that I won’t contract an STD if I choose to be sexually active.”
- B. “Abstinence is the only sure way to avoid an STD.”
- C. “If I use a condom with spermicide, I will be safer than if I don’t use one.”
- D. “If I question my partner about past sexual encounters, I can avoid STDs.”
Correct Answer: D
Rationale: The correct answer is D. This statement indicates a need for additional instruction because questioning a partner about past sexual encounters may not be a reliable method to avoid STDs. Here's the rationale:
1. A: Correct - Acknowledges the reality that engaging in sexual activity carries risks, even with precautions.
2. B: Correct - Emphasizes that abstinence is the most effective way to prevent STD transmission.
3. C: Correct - Using a condom with spermicide can reduce the risk of STD transmission, although it's not foolproof.
4. D: Incorrect - Relying solely on partner questioning is not a comprehensive or foolproof method to prevent STDs. It overlooks the potential for misinformation or lack of disclosure from the partner.
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A client is diagnosed with diabetes mellitus. Which assessment finding best supports a nursing diagnosis of Ineffective individual coping related to diabetes mellitus?
- A. Recent weight gain of 20 lb
- B. Skipping insulin doses during illness
- C. Failure to monitor blood glucose
- D. Crying whenever diabetes is levels mentioned
Correct Answer: D
Rationale: The correct answer is D because crying whenever diabetes is mentioned indicates emotional distress, a key component of ineffective coping. This response suggests the client is overwhelmed by the diagnosis, affecting their ability to cope effectively. In contrast, choices A, B, and C focus more on physical aspects and management of diabetes, not coping mechanisms. Weight gain could be related to poor diet or medication side effects, skipping insulin doses might indicate non-adherence, and failure to monitor blood glucose could be due to lack of knowledge or resources. Overall, D is the best choice as it directly relates to the client's emotional response to the diagnosis.
While the patient’s lower extremity, which is in a cast, is assessed, the patient tells the nurse about an inability to rest at night. The nurse disregards this information, thinking that no correlation has been noted between having a leg cast and developing restless sleep. Which action would have been best for the nurse to take?
- A. Tell the patient to just focus on the leg and cast right now.
- B. Document the sleep patterns and information in the patient’s chart.
- C. Explain that a more thorough assessment will be needed next shift.
- D. Ask the patient about usual sleep patterns and the onset of having difficulty resting.
Correct Answer: D
Rationale: The correct answer is D because it involves a comprehensive approach to addressing the patient's concern. By asking the patient about usual sleep patterns and the onset of having difficulty resting, the nurse can gather important information to assess the potential correlation between the leg cast and restless sleep. This approach demonstrates active listening and shows concern for the patient's well-being.
Option A is incorrect because it dismisses the patient's concern and does not address the underlying issue. Option B is also incorrect as it focuses solely on documentation without actively addressing the patient's concern. Option C is not the best choice as it delays addressing the patient's immediate need for help with sleeping, which may impact their overall recovery.
A 40 year-old female nurse had a fecal impaction and was admitted to the hospital. The physician orders an oil retention enema followed by a cleansing enema. What is the rationale for administering the oiul enema first?
- A. lubricate the walls of the intestinal tract
- B. soften the fecal mass and lubricate the walls of the rectum and colon
- C. reduce bacterial content of the fecal mass
- D. coat the walls of the intestines to prevent irritation by the hardened fecal mass
Correct Answer: B
Rationale: The correct answer is B: soften the fecal mass and lubricate the walls of the rectum and colon. First, the oil retention enema helps soften the fecal mass, making it easier to pass. Second, the oil lubricates the walls of the rectum and colon, reducing friction and making the passage of stool smoother. This helps prepare the fecal impaction for removal during the subsequent cleansing enema. Choices A, C, and D are incorrect because they do not directly address the primary goal of softening the fecal mass and lubricating the walls of the intestines to facilitate the removal of the impaction.
Several days before admission, a client reports finding a small lump in the left breast near the nipple. What should the nurse tell the client to do?
- A. Inform the physician immediately
- B. Squeeze the nipple to check for drainage
- C. Check the area after the next menstrual period
- D. Put a heating pad on the area to reduce inflammation
Correct Answer: A
Rationale: The correct answer is A: Inform the physician immediately. This is because finding a lump in the breast could be a sign of breast cancer, and early detection is crucial for effective treatment. The nurse should advise the client to seek medical evaluation promptly for further assessment, such as a mammogram or biopsy.
Choice B is incorrect because squeezing the nipple could potentially worsen the condition or spread cancerous cells if present. Choice C is incorrect as waiting until after the next menstrual period may delay necessary medical attention. Choice D is incorrect as using a heating pad could mask symptoms and delay proper diagnosis and treatment.
Rehabilitation plans for Mr. Gabatan;
- A. Should be left up to Mr. Gabatan and his family
- B. Should be considered and planned for early in his care
- C. Are not necessary, because he will return to former activities
- D. Are not necessary, because he will probably not able to work again Ms. J.K. is a 24-year old woman admitted to the neurosurgery floor 2 days following a hypophysectomy for a pituitary tumor. She is alert, oriented, and eager to return to her job as an executive to the hospital director. She is alert, oriented and eager to return to her job as an executive assistant to the hospital director. She calls the nurse to her room to express her concern about the frequency of urination she is experiencing, as well as the feeling of weakness that began this morning.
Correct Answer: B
Rationale: The correct answer is B because rehabilitation plans should be considered and planned for early in Mr. Gabatan's care to ensure the best outcomes. By addressing rehabilitation early, healthcare professionals can tailor interventions to his specific needs, promote independence, and prevent complications. This proactive approach enhances Mr. Gabatan's quality of life and functional abilities.
Choices A, C, and D are incorrect:
A: Leaving rehabilitation plans solely up to Mr. Gabatan and his family may not ensure comprehensive care and could lead to delays or inadequate support.
C: Assuming Mr. Gabatan will return to former activities without proper rehabilitation assessment and planning overlooks potential limitations and needs.
D: Assuming Mr. Gabatan will not be able to work again without proper rehabilitation evaluation and interventions may limit his potential for recovery and independence.