Nokea
A nurse is conducting a nursing health history. Which component will the nurse address?
- A. Nurse’s concerns
- B. Patient expectations
- C. Current treatment orders
- D. Nurse’s goals for the patient
Correct Answer: B
Rationale: The correct answer is B: Patient expectations. During a nursing health history, the nurse focuses on gathering information about the patient's health concerns, medical history, lifestyle, and expectations for their care. Addressing patient expectations is crucial for providing patient-centered care and establishing a therapeutic relationship. The other choices are incorrect because:
A: Nurse's concerns are not the primary focus of a nursing health history.
C: Current treatment orders are important but are typically addressed during a physical assessment or when implementing care.
D: Nurse's goals for the patient are important but should be developed in collaboration with the patient based on their needs and preferences.
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A 58-year-old man is diagnosed with cancer of the larynx. Which of the ff. are early symptoms of this cancer?
- A. Anemia and fatigue
- B. A noticeable lump in the neck
- C. Crackles and stridor
- D. Dysphagia or hoarseness
Correct Answer: D
Rationale: The correct answer is D: Dysphagia or hoarseness. In laryngeal cancer, dysphagia and hoarseness are early symptoms due to vocal cord involvement. Hoarseness results from vocal cord paralysis, while dysphagia occurs when the tumor obstructs the esophagus. Anemia and fatigue (choice A) are nonspecific symptoms seen in various conditions. A noticeable lump in the neck (choice B) typically indicates metastasis to the lymph nodes, which occurs later in laryngeal cancer. Crackles and stridor (choice C) are more associated with respiratory conditions rather than laryngeal cancer.
An adult has been treated for pulmonary tuberculosis and is being discharged home with his wife and two young children. His wife asks how TB is passed from one person to another so she can prevent anyone from catching it. How should the nurse respond?
- A. You should wear gloves when handling his linen and bedding
- B. You should keep the windows and doors closed so as not to spread the droplets
- C. He must be careful to cough into a handkerchief that is washed in hot water or discarded
- D. Make sure to boil all water before drinking or using it
Correct Answer: C
Rationale: Rationale:
Step 1: Coughing is the primary way TB bacteria are spread.
Step 2: By coughing into a handkerchief or tissue, the TB bacteria are contained.
Step 3: Washing the handkerchief in hot water or discarding it prevents the bacteria from spreading.
Step 4: This method reduces the risk of infecting family members.
Summary of Incorrect Choices:
A: Wearing gloves does not prevent airborne transmission of TB.
B: Keeping windows closed can increase the concentration of bacteria in the air.
D: Boiling water is not necessary to prevent TB transmission.
Which of the ff. problems during the immediate postoperative course ff. lumbar microdiskectomy should be reported to the physician immediately?
- A. Incisional pain
- B. Inability to move affected leg
- C. Two-inch area of bleeding on dressing
- D. Muscle spasm of affected
Correct Answer: B
Rationale: The correct answer is B because the inability to move the affected leg post lumbar microdiskectomy could indicate a serious complication like nerve damage or blood clot. This would require immediate medical attention to prevent further complications. Incisional pain (A) is common and can be managed with pain medication. A two-inch area of bleeding on the dressing (C) is concerning but can be managed with proper wound care unless it is excessive. Muscle spasm (D) is also common postoperatively and can be managed with medications or physical therapy.
A male client, age 45, undergoes a lumbar puncture in which CSF was extracted for a particular neurologic diagnostic procedure. After the procedure, he complains of dizziness and a slight headache. Which of the ff steps must the nurse take to provide comfort to the client? Choose all that apply
- A. Position the client flat for at least 3 hrs or as directed by the physician
- B. Encourage a liberal fluid intake
- C. Keep the room well lit and play some soothing music in the ground
- D. Help the client ambulate and perform a few light leg exercises#
Correct Answer: A
Rationale: The correct answer is A: Position the client flat for at least 3 hrs or as directed by the physician.
Rationale:
1. Positioning the client flat helps prevent post-lumbar puncture headache by allowing the CSF to replenish and stabilize the pressure in the spinal canal.
2. The recommended time frame of 3 hours allows for adequate CSF reabsorption and reduces the likelihood of headache.
3. Following physician's direction is crucial to individualize care based on the specific situation.
Summary of other choices:
B: Encouraging fluid intake is generally good practice but may not directly alleviate post-lumbar puncture headache.
C: Keeping the room well lit and playing soothing music may not address the physiological cause of the client's symptoms.
D: Ambulation and leg exercises are not recommended immediately post-lumbar puncture as they may exacerbate dizziness and headache.
A nurse is teaching high school students about transmission of the human immunodeficiency virus (HIV). Which comment by a student warrants clarification by the nurse?
- A. “A man should wear a latex condom during intimate sexual contact.”
- B. “I’ve heard about people who got AIDS from blood transfusions.”
- C. “I won’t donate blood because I don’t want to get AIDS.”
- D. “IV drug users can get HIV from sharing needles.”
Correct Answer: C
Rationale: The correct answer is C. This statement warrants clarification as donating blood does not put individuals at risk of getting HIV. Blood donation involves a sterile process that ensures safety. Choice A is correct as using condoms can help prevent the transmission of HIV. Choice B is incorrect because modern blood screening techniques have greatly reduced the risk of HIV transmission through blood transfusions. Choice D is also correct as sharing needles is a high-risk behavior for HIV transmission. In summary, only choice C is incorrect as donating blood does not pose a risk of acquiring HIV.