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A nurse working in a community health setting is performing primary health screenings. Which individual is at highest risk for contracting an HIV infection?
- A. A 17-year-old who is sexually active with numerous partners.
- B. A 45-year-old lesbian who has been sexually active with two partners in the past year.
- C. A 30-year-old cocaine user who inhales the drug and works in a topless bar.
- D. A 34-year-old male homosexual who is in a monogamous relationship.
Correct Answer: A
Rationale: The correct answer is A. A 17-year-old who is sexually active with numerous partners is at the highest risk for contracting an HIV infection due to engaging in risky sexual behavior with multiple partners, increasing the likelihood of exposure to the virus. Choice B is less risky as the individual has had a relatively lower number of sexual partners in the past year. Choice C, although involving drug use, does not directly correlate with a higher risk of contracting HIV unless needles are shared. Choice D, a 34-year-old male homosexual in a monogamous relationship, has a lower risk compared to choice A as long as the relationship remains monogamous.
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A client was admitted with a diagnosis of pneumonia. When auscultating the client's breath sounds, the nurse hears inspiratory crackles in the right base. Temperature is 102.3 degrees Fahrenheit orally. What finding would the nurse expect?
- A. Flushed skin
- B. Bradycardia
- C. Mental confusion
- D. Hypotension
Correct Answer: C
Rationale: The correct answer is C: Mental confusion. In this scenario, the client's high fever and pneumonia diagnosis indicate an infection. Infections, especially in older adults, can lead to mental confusion due to the body's systemic response to the infection. Flushed skin (choice A) is more commonly associated with fever but does not specifically relate to the client's condition. Bradycardia (choice B) and hypotension (choice D) are less likely findings in a client with pneumonia and a high fever; instead, tachycardia and increased blood pressure are more commonly seen in response to infection.
A 16-year-old female client returns to the clinic because she is pregnant for the third time by a new boyfriend. Which vaccine should the nurse plan to administer?
- A. MMR
- B. Hepatitis B
- C. Human papillomavirus
- D. Pneumococcal
Correct Answer: B
Rationale: The correct answer is B, Hepatitis B. The Hepatitis B vaccine is crucial for pregnant women to prevent transmission of the virus to the baby during childbirth. Option A, MMR (Measles, Mumps, Rubella) vaccine, is not indicated during pregnancy. Option C, Human papillomavirus vaccine, is recommended for prevention of HPV infections but is not specifically indicated during pregnancy. Option D, Pneumococcal vaccine, is important for certain populations but is not the priority vaccine for a pregnant woman in this scenario.
A client with a history of seizures is receiving phenytoin (Dilantin). The nurse should monitor the client for which of the following side effects?
- A. Hypertension
- B. Hyperglycemia
- C. Gingival hyperplasia
- D. Hypokalemia
Correct Answer: C
Rationale: The correct answer is C: Gingival hyperplasia. Phenytoin can cause gingival hyperplasia, characterized by an overgrowth of gum tissue. It is important for the nurse to monitor the client for this side effect as it can lead to oral health issues. Choices A, B, and D are incorrect. Phenytoin does not typically cause hypertension, hyperglycemia, or hypokalemia as common side effects.
What components should a nurse include when conducting a community health assessment?
- A. Personal health history of community members
- B. Number of hospitals in the community
- C. Demographic data, health status indicators, and community resources
- D. Results of laboratory tests
Correct Answer: C
Rationale: When conducting a community health assessment, it is essential to gather demographic data (such as age, gender, ethnicity), health status indicators (like prevalence of diseases, mortality rates), and information on community resources (such as healthcare facilities, social services). These components help in understanding the health needs of the community and planning appropriate interventions. Choices A, B, and D are not typically part of a community health assessment as they focus on individual health data or specific medical information rather than the broader population health perspective required for community assessments.
In providing comprehensive family health care, the nurse utilizes four (4) basic processes. These are listed in the order in which they are carried out as follows:
- A. assessment, planning, intervention, and evaluation
- B. assessment, intervention, planning, and evaluation
- C. planning, assessment, intervention, and evaluation
- D. planning, intervention, evaluation, and assessment
Correct Answer: A
Rationale: The correct order for the basic processes in providing comprehensive family health care is assessment, planning, intervention, and evaluation. Assessment is the first step to gather information, followed by planning to set goals and strategies, then intervention to implement the plan, and finally evaluation to assess the outcomes. Choice A is correct as it follows this logical sequence. Choices B, C, and D are incorrect because they do not follow the correct order of these essential processes in nursing care.