Nokea
A nurse is addressing the incidence and prevalence of HIV infection among older adults. What principle should guide the nurses choice of educational interventions?
- A. Many older adults do not see themselves as being at risk for HIV infection.
- B. Many older adults are not aware of the difference between HIV and AIDS.
- C. Older adults tend to have more sex partners than younger adults.
- D. Older adults have the highest incidence of intravenous drug use.
Correct Answer: A
Rationale: The correct answer is A because it addresses the key issue of perception of risk among older adults. Many older adults may not perceive themselves as being at risk for HIV infection due to misconceptions or lack of awareness. This principle guides the nurse to tailor educational interventions to address this specific barrier. Choices B, C, and D are incorrect as they do not directly address the perception of risk among older adults. Older adults' awareness of HIV/AIDS, number of sex partners, or incidence of intravenous drug use are not the primary factors influencing their perception of HIV risk.
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The nurse is reviewing the instructions given to a patient at 24 weeks’ gestation for a glucose challenge test (GCT). The nurse determines that the patient understands the teaching when she makes which statement?
- A. “I have to fast the night before the test.”
- B. “I will drink a sugary solution containing 100 g of glucose.”
- C. “I will have blood drawn at 1 hour after I drink the glucose solution.”
- D. “I should keep track of my baby’s movements between now and the test.”
Correct Answer: C
Rationale: The correct answer is C: “I will have blood drawn at 1 hour after I drink the glucose solution.” This statement demonstrates understanding of the GCT procedure. The glucose challenge test involves drinking a sugary solution, followed by blood drawn 1 hour later to measure blood glucose levels. This timing is crucial for assessing the body's ability to metabolize glucose, which helps in diagnosing gestational diabetes.
Explanation of why the other choices are incorrect:
A: “I have to fast the night before the test.” - This is incorrect as fasting is not required for the GCT.
B: “I will drink a sugary solution containing 100 g of glucose.” - This is incorrect as the GCT typically involves drinking a solution with a standardized amount of glucose, usually 50 g, not 100 g.
D: “I should keep track of my baby’s movements between now and the test.” - This is unrelated to the GCT procedure and does not demonstrate understanding of the
When planning discharge teaching with a patient who has undergone a total mastectomy with axillary dissection, the nurse knows to instruct the patient that she should report what sign or symptom to the physician immediately?
- A. Fatigue
- B. Temperature greater than 98.5F
- C. Sudden cessation of output from the drainage device
- D. Gradual decline in output from the drain
Correct Answer: C
Rationale: The correct answer is C: Sudden cessation of output from the drainage device. This is crucial because it can indicate a potential complication like a blocked drain or infection, requiring immediate medical attention to prevent further issues. Other choices like fatigue (A) are common after surgery but not urgent. Temperature elevation (B) may indicate infection but is not as critical as sudden cessation of drainage. Gradual decline in output (D) is expected as the drainage decreases over time, so it doesn't require immediate reporting.
A patient has a decreased gag reflex, left-sided weakness, and drooling. Which action will the nurse take when feeding this patient?
- A. Position in semi-Fowler’s.
- B. Flex head with chin tuck.
- C. Place food on left side.
- D. Offer fruit juice.
Correct Answer: B
Rationale: The correct answer is B: Flex head with chin tuck. This position helps prevent aspiration by closing off the airway during swallowing. Flexing the head and tucking the chin promotes safe swallowing and reduces the risk of choking. Placing food on the left side (choice C) is not relevant to addressing the patient's symptoms. Positioning in semi-Fowler's (choice A) may not directly address the swallowing difficulty. Offering fruit juice (choice D) does not address the patient's specific feeding needs and may not be safe if the patient has swallowing difficulties.
A nurse is using core measures to reduce healthdisparities. Which group should the nurse focus on to cause themost improvement in core measures?
- A. Caucasians
- B. Poor people
- C. Alaska Natives
- D. American Indians
Correct Answer: B
Rationale: The correct answer is B: Poor people. Focusing on poor people is likely to cause the most improvement in core measures because individuals living in poverty often face multiple barriers to accessing healthcare and have higher rates of chronic conditions. By targeting this group, the nurse can address social determinants of health, improve healthcare access, and address disparities in healthcare outcomes. Other choices (A, C, D) are not as impactful as poverty is a significant factor influencing health disparities.
The nurse care plan for a patient with AIDS includes the diagnosis of Risk for Impaired Skin Integrity. What nursing intervention should be included in the plan of care?
- A. Maximize the patients fluid intake.
- B. Provide total parenteral nutrition (TPN).
- C. Keep the patients bed linens free of wrinkles.
- D. Provide the patient with snug clothing at all times.
Correct Answer: C
Rationale: The correct answer is C: Keep the patient's bed linens free of wrinkles. This intervention is important in preventing pressure ulcers, a common complication in patients with impaired skin integrity. Wrinkles in bed linens can create pressure points on the skin, leading to skin breakdown. By keeping the bed linens smooth and wrinkle-free, the patient's skin is protected from excessive pressure, reducing the risk of impaired skin integrity.
A: Maximizing fluid intake is important for overall health but is not directly related to preventing impaired skin integrity.
B: Providing total parenteral nutrition may support the patient's nutritional needs but does not specifically address the risk of impaired skin integrity.
D: Providing snug clothing can increase friction and pressure on the skin, potentially worsening the risk of impaired skin integrity.