Nokea
A female client diagnosed with genital herpes simplex virus 2 (HSV 2) complains of dysuria, dyspareunia, leukorrhea, and lesions on the labia and perianal skin. A primary nursing action with the focus of comfort should be to
- A. Suggest 3 to 4 warm sitz baths per day
- B. Cleanse the genitalia twice a day with soap and water
- C. Spray warm water over genitalia after urination
- D. Apply heat or cold to lesions as desired
Correct Answer: A
Rationale: The correct answer is to suggest 3 to 4 warm sitz baths per day. Warm sitz baths can soothe the irritated genital area, reduce pain, and promote healing of the lesions associated with genital herpes. Cleansing the genitalia with soap and water or spraying warm water over the genitalia after urination may further irritate the lesions. Applying heat or cold to lesions as desired may not provide the same level of comfort and healing as warm sitz baths.
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The nurse is working in a community health clinic that serves a diverse population. Which of the following actions best demonstrates cultural competence?
- A. Learning about the cultural practices of the clinic's client population
- B. Providing translation services for non-English speaking clients
- C. Treating all clients the same regardless of their background
- D. Encouraging clients to adopt mainstream health practices
Correct Answer: A
Rationale: Learning about the cultural practices of the clinic's client population is the best way to demonstrate cultural competence. This action shows respect for the diverse backgrounds of the clients and helps in providing care that is sensitive to their cultural beliefs and practices. Providing translation services (Choice B) is important for effective communication but may not address the deeper aspects of cultural competence. Treating all clients the same (Choice C) may overlook the unique needs that arise from cultural differences. Encouraging clients to adopt mainstream health practices (Choice D) may not be appropriate or respectful of their cultural traditions and preferences.
The nurse is caring for a child with cystic fibrosis. The nurse would anticipate that the child would be deficient in which vitamins?
- A. B, D, and K
- B. A, D, and K
- C. A, C, and D
- D. A, B, and C
Correct Answer: B
Rationale: Children with cystic fibrosis often have difficulty absorbing fat-soluble vitamins (A, D, and K) due to pancreatic insufficiency, making supplementation necessary. Choice A (B, D, and K) is incorrect because vitamin A deficiency is not commonly associated with cystic fibrosis. Choice C (A, C, and D) is incorrect as vitamin C deficiency is not typically related to cystic fibrosis. Choice D (A, B, and C) is incorrect as vitamin B deficiencies are not commonly seen in cystic fibrosis but rather fat-soluble vitamin deficiencies.
A client with acute pancreatitis is experiencing severe abdominal pain. The nurse should implement which of the following interventions?
- A. Encourage oral intake
- B. Administer opioid analgesics
- C. Apply a heating pad to the abdomen
- D. Place the client in a supine position
Correct Answer: B
Rationale: The correct intervention for a client with acute pancreatitis experiencing severe abdominal pain is to administer opioid analgesics. Opioids are effective in managing the severe pain associated with acute pancreatitis. Encouraging oral intake may exacerbate the symptoms and is contraindicated due to the need for bowel rest. Applying a heating pad to the abdomen can worsen inflammation and should be avoided. Placing the client in a supine position may not provide relief and could potentially lead to increased discomfort.
In planning for the nursing care of the sick person in the home, the major point that the nurse must keep in mind is:
- A. who will be responsible for the patient during the nurse's absence from the home
- B. economic level of the family
- C. the availability of the nearest hospital
- D. whether or not the patient is under a private physician
Correct Answer: A
Rationale: The correct answer is A because ensuring someone is responsible for the patient is crucial for continuous care. The presence of a caregiver during the nurse's absence ensures the patient's safety and well-being. Choice B, economic level of the family, is important but not the major point when planning nursing care in the home. Choice C, the availability of the nearest hospital, is significant but doesn't address the day-to-day care in the home. Choice D, whether or not the patient is under a private physician, is relevant but not as critical as ensuring someone is available to care for the patient at all times.
The nurse is caring for a child who has just returned from surgery following a tonsillectomy and adenoidectomy. Which action by the nurse is appropriate?
- A. Offer ice chips every 2 hours
- B. Place the child in a semi-Fowler's position
- C. Encourage the child to drink from a cup
- D. Observe swallowing patterns
Correct Answer: D
Rationale: Observing swallowing patterns is crucial post-tonsillectomy and adenoidectomy to detect signs of bleeding. Offering ice chips instead of ice cream helps prevent throat irritation. Placing the child in a semi-Fowler's position promotes airway patency and reduces the risk of aspiration. Encouraging the child to drink from a cup instead of a straw minimizes the risk of dislodging the surgical site.