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A nurse is counseling a client who is to undergo enzyme-linked immunosorbent assay (ELISA) testing for HIV. Which of the following information should the nurse include?
- A. The test monitors progression of the disease
- B. The test measures antibodies to the virus
- C. The test results are accurate 24 hr after exposure to the virus
- D. A positive result requires initiating immunoglobulin administration
Correct Answer: B
Rationale: The correct answer is B because ELISA testing for HIV measures antibodies to the virus, indicating exposure to the virus. This is crucial for diagnosing HIV infection. Choice A is incorrect because ELISA does not monitor disease progression. Choice C is incorrect as it takes weeks, not hours, for accurate results post-exposure. Choice D is incorrect as immunoglobulin administration is not the treatment for a positive HIV result.
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A nurse case manager is providing discharge planning for a client. The nurse is functioning in which of the following roles when arranging for the delivery of medical equipment to the client's home?
- A. Consultant
- B. Systems allocator
- C. Coordinator
- D. Advocate
Correct Answer: C
Rationale: The correct answer is C: Coordinator. In this scenario, the nurse is functioning as a coordinator by arranging for the delivery of medical equipment to the client's home. As a coordinator, the nurse is organizing and facilitating the necessary resources and services to meet the client's needs. This role involves collaborating with various healthcare providers and agencies to ensure a smooth transition for the client post-discharge.
The other choices are incorrect because:
A: Consultant - This role involves providing expert advice or recommendations based on specialized knowledge. The nurse in the scenario is not simply providing advice but actively coordinating services.
B: Systems allocator - This role involves allocating resources within a healthcare system. While the nurse is arranging for resources, the focus is on the specific client's needs rather than broader system allocation.
D: Advocate - This role involves speaking up for the client's rights and needs. While advocacy may be a part of the nurse's role, in this scenario, the primary focus is on coordination of services.
An occupational health nurse is discussing health promotion with a client who has a history of obesity. Which of the following comments indicates the client is using rationalization as a coping mechanism?
- A. I have lots of health problems from being obese
- B. I am obese, it's in my genes
- C. I have difficulty resisting the items in vending machines
- D. I know you don't like me because I am obese
Correct Answer: B
Rationale: The correct answer is B because the client is using rationalization by attributing their obesity to genetics rather than taking personal responsibility. This deflects accountability and provides a justification for their weight issue. Choice A acknowledges the health problems related to obesity. Choice C acknowledges a specific struggle with resisting temptations. Choice D reflects projection, attributing dislike to the nurse. Other choices are incomplete.
A nurse is conducting a community assessment. Which of the following information should the nurse include as part of the windshield survey?
- A. Demographic data
- B. Mortality rate
- C. Informant interviews
- D. Housing quality
Correct Answer: D
Rationale: The correct answer is D: Housing quality. In a windshield survey, the nurse observes the community from a car to assess physical environment, including housing conditions. This information is crucial for identifying health risks and community needs. Demographic data (A) and mortality rates (B) are important but are typically gathered through other means. Informant interviews (C) involve talking to community members, not part of a windshield survey. Other choices (E, F, G) are not relevant to a windshield survey.
A home health nurse is planning the initial home visit for a client who has dementia and lives with his adult son's family. Which of the following actions should the nurse take first during the visit?
- A. Encourage the family to join a support group
- B. Provide the family with information about respite care
- C. Educate the family regarding the progression of dementia
- D. Engage the family in informal conversation
Correct Answer: D
Rationale: The correct answer is D: Engage the family in informal conversation. This is the first action the nurse should take during the initial visit because building rapport and establishing trust with the family is crucial in the care of a client with dementia. By engaging in informal conversation, the nurse can observe family dynamics, assess the family's understanding of the client's condition, and gather valuable information about the client's daily routine and needs. This lays the foundation for effective communication and collaboration moving forward.
A: Encouraging the family to join a support group can be beneficial but should come after establishing rapport and assessing the family's needs.
B: Providing information about respite care is important, but it is not the priority during the initial visit.
C: Educating the family about the progression of dementia is important, but it should be done after building rapport and assessing their current understanding.
A charge nurse on a medical-surgical unit is assisting with the emergency response plan following an external disaster in the community. In anticipation of multiple client admissions, which of the following current clients should the nurse recommend for early discharge?
- A. A client who is receiving heparin for deep-vein thrombosis.
- B. A client who is 1 day postoperative following a vertebroplasty.
- C. A client who has cancer and a sealed implant for radiation therapy.
- D. A client who has COPD and a respiratory rate of 44/min.
Correct Answer: B
Rationale: The correct choice is B: A client who is 1 day postoperative following a vertebroplasty. This client is the most stable among the options provided. Early discharge is appropriate because the client is 1 day postoperative, likely past the critical immediate postoperative period. Discharging this client will create space for incoming emergency admissions. Choice A should not be discharged early as managing deep-vein thrombosis with heparin requires close monitoring to prevent complications. Choice C should not be discharged early due to the need for ongoing cancer treatment. Choice D should not be discharged early as the client with COPD and a high respiratory rate of 44/min requires close monitoring and intervention to prevent respiratory distress.