Nokea
A nurse is caring for a patient hospitalized with AIDS. A friend comes to visit the patient and privately asks the nurse about the risk of contracting HIV when visiting the patient. What is the nurses best response?
- A. Do you think that you might already have HIV?
- B. Dont worry. Your immune system is likely very healthy.
- C. AIDS isnt transmitted by casual contact.
- D. You cant contract AIDS in a hospital setting.
Correct Answer: C
Rationale: The nurse's best response is option C - "AIDS isn't transmitted by casual contact." This response is accurate and provides the necessary information to address the friend's concern. It is important to educate the friend that HIV/AIDS is not transmitted through casual contact such as visiting a patient in the hospital. By stating this fact clearly, the nurse can help alleviate any unfounded fears or misconceptions the friend may have about contracting HIV while visiting the patient. This response promotes understanding and helps reduce stigma associated with HIV/AIDS, while also emphasizing the importance of accurate information in preventing the spread of the virus.
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A patient confides to the nurse that he cannot engage in sexual activity. The patient is 27 years old and has no apparent history of chronic illness that would contribute to erectile dysfunction. What does the nurse know will be ordered for this patient to assess his sexual functioning?
- A. Sperm count
- B. Ejaculation capacity tests
- C. Engorgement tests
- D. Nocturnal penile tumescence tests
Correct Answer: D
Rationale: Nocturnal penile tumescence tests are used to assess erectile dysfunction in men who are unable to engage in sexual activity. It measures the frequency and strength of erections that occur during sleep, which can provide valuable information about a man's erectile function and whether there may be underlying physiological causes for his inability to engage in sexual activity. This test can help determine if the patient's erectile dysfunction is due to physical or psychological factors. A sperm count, ejaculation capacity tests, and engorgement tests are not typically ordered to assess sexual functioning in this case.
A nurse is providing care to a group of patients.Which situation will require the nurse to obtain a telephone order?
- A. As the nurse and health care provider leave a patient’s room, the primary care provider gives the nurse an order.
- B. At 0100, a patient’s blood pressure drops from 120/80 to 90/50, and the incision dressing is saturated with blood.
- C. At 0800, the nurse and health care provider make rounds, and the primary care provider tells the nurse a diet order.
- D. A nurse reads an order correctly as written by the health care provider in the patient’s medical record
Correct Answer: B
Rationale: In this situation, the nurse needs to obtain a telephone order because the patient's condition has changed significantly. The drop in blood pressure from 120/80 to 90/50 along with the saturated incision dressing indicates a potential complication or need for immediate intervention. The nurse must act quickly to address the situation and may require additional orders from the primary care provider over the phone to manage the patient's condition effectively. The urgency and critical nature of the situation necessitate obtaining a telephone order promptly to ensure the best outcome for the patient.
The nurse is planning discharge education for a patient with trigeminal neuralgia. The nurse knows to include information about factors that precipitate an attack. What would the nurse be correct in teaching the patient to avoid?
- A. Washing his face
- B. Exposing his skin to sunlight
- C. Using artificial tears
- D. Drinking large amounts of fluids
Correct Answer: A
Rationale: Trigeminal neuralgia is a condition characterized by severe facial pain due to irritation or damage to the trigeminal nerve. Factors such as touching or lightly brushing the face, chewing, speaking, or even encountering a breeze can trigger an attack. Therefore, activities like washing the face that involve touching or stimulating the trigeminal nerve can precipitate an attack in patients with trigeminal neuralgia. It is important for patients to be aware of these triggers to help manage and prevent episodes of pain.
To honor cultural values of patients from different ethnic/religious groups, which actions demonstrate culturally sensitive care by the nurse? (Select allthat apply.)
- A. Allows fasting on Yom Kippur for a Jewish patient
- B. Allows caffeine drinks for a Mormon patient
- C. Serves no ham products to a Muslim patient
- D. Serves kosher foods to a Christian patient
Correct Answer: A
Rationale: A. Allowing fasting on Yom Kippur for a Jewish patient demonstrates culturally sensitive care by respecting and accommodating the religious practices of the patient. Yom Kippur is an important day of fasting and repentance in the Jewish faith, and by allowing the patient to observe this practice, the nurse shows understanding and support.
A nurse uses SBAR when providing a hands-off report to the oncoming shift. What is the rationale for the nurse’s action?
- A. To promote autonomy
- B. To use common courtesy
- C. To establish trustworthiness
- D. To standardize communication
Correct Answer: D
Rationale: SBAR stands for Situation, Background, Assessment, and Recommendation. It is a structured method of communication that healthcare providers use to effectively communicate important information about a patient. The use of SBAR helps ensure that all necessary details are communicated in a clear, concise, and systematic manner, reducing the risk of miscommunication and errors. By standardizing communication using SBAR, nurses can provide a comprehensive report during a shift change, promoting continuity of care and patient safety. Thus, the main rationale for a nurse using SBAR when providing a hands-off report is to standardize communication and improve the quality of patient care.