Nokea
A nurse is reinforcing teaching with a client who has herpes simplex virus type 2. Which of the following statements by the client indicates an understanding of the teaching?
- A. I am only contagious while the lesions are present.
- B. The virus cannot spread to areas other than the genital area.
- C. I can have unprotected sex as long as I am taking acyclovir.
- D. The lesions may reoccur in times of stress.
Correct Answer: D
Rationale: Herpes simplex virus type 2 can recur during stress due to immune suppression, indicating client understanding.
You may also like to solve these questions
A nurse is transporting a client who has pneumonia and is on droplet precautions to radiology. Which of the following safety measures should the nurse take while transporting the client?
- A. The client should wear a mask during transport.
- B. The nurse should wear a mask during transport.
- C. The nurse should wear a gown during transport.
- D. The client should wear a gown during transport.
Correct Answer: A
Rationale: The client wearing a mask during transport prevents the spread of droplet pathogens, consistent with droplet precautions for pneumonia.
Nurses' Notes
Vital Signs
Laboratory Results
Provider Prescriptions
Day 1, 1000:
The client reports mid abdominal pain. Client reports pain as 7 on a scale of 0 to 10. The client states, "I haven't had a bowel movement in 4 days." The client states, "I also have vomited once or twice."
Physical Exam:
General: uncomfortable, grimacing
HEENT: dry mucous membranes
Cardiovascular: S1, S2, no murmur
Respiratory: bilateral breath sounds clear
Gastrointestinal: tenderness to palpation, high-pitched bowel sounds
Skin: no jaundice noted
Social history: drinks 1 to 2 glasses of wine daily. Client reports no tobacco use.
Day 1, 1100:
Morphine administered as prescribed. IV fluids with potassium supplements initiated. Nasogastric tube inserted into left nare and set to low wall suction.
Day 4, 1000:
Client reports that abdominal pain has decreased to 3 on a scale of 0 to 10. Client states, "I feel less nauseous today and haven't vomited since yesterday." Client reports having a small bowel movement early this morning.
Physical exam:
General: Appears more comfortable, not grimacing.
HEENT: Mucous membranes moist.
Cardiovascular: S1, S2, no murmur.
Respiratory: Bilateral breath sounds clear.
Gastrointestinal:
Mild tenderness to palpation.
Bowel sounds present and more regular, less high-pitched.
Skin: No jaundice noted, skin warm and dry.
The nurse continues to assist with the care of the client.
The nurse continues to assist with the care of the client. Which of the following findings indicates that the client's condition has improved?
- A. Fluid intake
- B. Temperature
- C. Wound findings
- D. Pain level
- E. Report of nausea
- F. Bowel sounds
Correct Answer: D,E,F
Rationale: Decreased pain (from 7 to 3), reduced nausea, and more regular bowel sounds indicate improvement in the client's condition, likely due to resolution of obstruction.
A nurse is reinforcing teaching with the family of a client who has methicillin-resistant Staphylococcus aureus (MRSA) of a leg wound and is on contact precautions. Which of the following statements by a family member indicates an understanding of the teaching?
- A. There is no cure for MRSA.
- B. We will need to wear masks when we are in the hospital room.
- C. MRSA only occurs in health care facilities.
- D. We should remove gloves before leaving the hospital room.
Correct Answer: D
Rationale: Removing gloves before leaving prevents the spread of MRSA, consistent with contact precautions.
A nurse is reinforcing teaching about ostomy supplies with a client who has a new colostomy. Which of the following information should the nurse include?
- A. Empty the pouch when it is 1/3 to 1/2 full.
- B. Use a standard enema set to irrigate the colostomy.
- C. Cleanse the skin surrounding the stoma with moisturizing soap.
- D. Cut the opening in the skin barrier 1/4 inch larger than the stoma.
Correct Answer: A
Rationale: Emptying the pouch when 1/3 to 1/2 full prevents leakage and maintains skin integrity, a key aspect of ostomy care.
A nurse is checking the abdominal incision of a client who is 24 hr postoperative. The nurse finds wound evisceration with protruding abdominal contents. The nurse should place the client into which of the following positions?
- A. Trendelenburg with legs extended
- B. Supine with knees flexed
- C. Semi-Fowler's with legs extended
- D. Left-lateral with knees flexed
Correct Answer: B
Rationale: Supine with knees flexed relaxes abdominal muscles, reducing pressure on the eviscerated wound until surgical intervention.