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A nurse is assessing the skin integrity of a patient who has AIDS. When performing this inspection, the nurse should prioritize assessment of what skin surfaces?
- A. Perianal region and oral mucosa
- B. Sacral region and lower abdomen
- C. Scalp and skin over the scapulae
- D. Axillae and upper thorax
Correct Answer: A
Rationale: The correct answer is A: Perianal region and oral mucosa. In patients with AIDS, these areas are more prone to opportunistic infections due to decreased immune function. The perianal region can be affected by conditions like anal warts or herpes, while the oral mucosa can develop oral thrush or other oral infections. By prioritizing assessment of these areas, the nurse can promptly identify any potential issues and initiate appropriate interventions.
Choice B: Sacral region and lower abdomen are not typically high-risk areas for skin integrity issues in AIDS patients.
Choice C: Scalp and skin over the scapulae are not commonly affected by opportunistic infections related to AIDS.
Choice D: Axillae and upper thorax are not as commonly affected as the perianal region and oral mucosa in AIDS patients.
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A nurse is teaching the staff about informatics.Which information from the staff indicates the nurse needs to follow up?
- A. To be proficient in informatics, a nurse should be able to discover, retrieve, and use information in practice.
- B. A nurse needs to know how to find, evaluate, and use information effectively.
- C. If a nurse has computer competency, the nurse is competent in informatics
- D. Nursing informatics is a recognized specialty area of nursing practice.
Correct Answer: C
Rationale: The correct answer is C. Computer competency does not equate to informatics competency. Informatics involves more than just basic computer skills; it encompasses the ability to use technology to manage and analyze data for improved healthcare outcomes.
A: This is a correct statement about informatics proficiency.
B: This is also a correct statement about the skills needed for informatics.
D: This is a true statement about nursing informatics being a recognized specialty, but it does not indicate a need for follow-up.
In summary, choice C is incorrect as it oversimplifies the concept of informatics, while choices A, B, and D provide accurate information related to informatics.
Examination of a newborn in the birth room reveals bilateral cataracts. Which disease process in the maternal history would likely cause this abnormality?
- A. Rubella
- B. Cytomegalovirus (CMV)
- C. Syphilis
- D. HIV
Correct Answer: A
Rationale: The correct answer is A: Rubella. Rubella infection during pregnancy can lead to congenital rubella syndrome, which includes bilateral cataracts as a characteristic feature. Rubella virus can cross the placenta and affect the developing fetus. Cytomegalovirus (CMV) can also cause congenital cataracts, but rubella is more commonly associated with this abnormality. Syphilis can cause other congenital abnormalities but not bilateral cataracts. HIV does not typically lead to bilateral cataracts in newborns.
Initiate feeding.
- A. 4, 2, 1, 5, 3
- B. 2, 4, 1, 3, 5
- C. 1, 4, 2, 3, 5
- D. 2, 1, 4, 5, 3
Correct Answer: B
Rationale: The correct answer is B (2, 4, 1, 3, 5) because it follows the correct sequential order for initiating feeding. First, you need to prepare the food (2), then set up the feeding area (4), followed by inviting the person to eat (1), serving the food (3), and finally allowing them to eat (5). The other choices do not adhere to the logical sequence required for initiating feeding. Choice A and D have incorrect sequences of steps, while Choice C has steps 1 and 4 switched, which disrupts the proper order of initiating feeding.
A patient with Parkinsons disease is experiencing episodes of constipation that are becoming increasingly frequent and severe. The patient states that he has been achieving relief for the past few weeks by using OTC laxatives. How should the nurse respond?
- A. Its important to drink plenty of fluids while youre taking laxatives.
- B. Make sure that you supplement your laxatives with a nutritious diet.
- C. Lets explore other options, because laxatives can have side effects and create dependency.
- D. You should ideally be using herbal remedies rather than medications to promote bowel function.
Correct Answer: C
Rationale: The correct answer is C: Lets explore other options, because laxatives can have side effects and create dependency. The rationale for this is that while laxatives provide temporary relief for constipation, using them long-term can lead to dependency, electrolyte imbalances, and other side effects. The nurse should address the root cause of constipation and explore alternative strategies such as dietary changes, increased fluid intake, exercise, and bowel training. Choices A and B focus on supportive measures rather than addressing the issue of potential dependency on laxatives. Choice D suggests herbal remedies without considering the individual's specific condition and medical history.
A nurse is using the explanatory model to determinethe etiology of an illness. Which questions should the nurse ask? (Select all that apply.)
- A. How should your sickness be treated?
- B. What do you call your problem?
- C. How does this illness work inside your body?
- D. What do you fear most about your sickness?
Correct Answer: B
Rationale: The correct answer is B: What do you call your problem? In the explanatory model, this question helps the nurse understand the patient's perspective and cultural beliefs about their illness. By asking how the patient labels their illness, the nurse gains insight into the patient's understanding of the illness, which can influence their treatment adherence and outcomes. The other options are incorrect because:
A: How should your sickness be treated? - This question focuses on treatment preferences rather than understanding the patient's beliefs.
C: How does this illness work inside your body? - This question is more aligned with the biomedical model, seeking physiological explanations rather than patient perspectives.
D: What do you fear most about your sickness? - While important for assessing emotional aspects, this question does not directly address the patient's explanatory model.