Nokea
A nurse working in the neonatal intensive care unit (NICU) teaches handwashing techniques to the parents of an infant who is receiving antibiotic treatment for a neonatal infection. The nurse determines that the parents understand the primary purpose of hand washing if which statement is made?
- A. It is primarily done to reduce their fears.
- B. It is primarily done to minimize the spread of infection to other siblings.
- C. It is primarily done to allow them an opportunity to communicate with each other and staff.
- D. It is primarily done to reduce the possibility of transmitting an environmental infection to the infant.
Correct Answer: D
Rationale: Appropriate hand washing by staff and parents has been effective for the prevention of nosocomial infections in nursery units. This action also promotes parents taking an active part in the care of their infant. Reducing fears and encouraging communication are not the primary reasons to perform hand washing. Because the infant already has an infection and is in the NICU, transference to siblings is not the best choice.
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The nurse is assessing a client who is suspected of having a diagnosis of testicular cancer. Which data will be most helpful for determining the client's risk for this type of cancer?
- A. Race
- B. Marital status
- C. Number of children
- D. Number of sexual partners
Correct Answer: A
Rationale: Race is a key risk factor for testicular cancer, with higher incidence in White males compared to other groups. Marital status, number of children, and sexual partners are not established risk factors for this cancer.
The nurse is working at an osteoporosis screening clinic and is interviewing and performing health assessments on women. Which clients are at greatest risk for developing osteoporosis? Select all that apply.
- A. An Asian woman
- B. A large-boned, dark-skinned woman
- C. A client who started menopause early
- D. A client with a family history of the disease
- E. A client who has a physically active lifestyle
- F. A client with an inadequate intake of calcium and vitamin D
Correct Answer: A,C,D,F
Rationale: Risk factors for osteoporosis include being of Asian or Caucasian descent, early menopause, a family history of osteoporosis, and inadequate intake of calcium and vitamin D. Large-boned, dark-skinned women (e.g., those of African descent) have a lower risk due to higher bone density. A physically active lifestyle is protective against osteoporosis, reducing the risk.
The home care nurse is evaluating a client's understanding of the self-management of trigeminal neuralgia. Which client statement indicates that there is a need for further teaching?
- A. I should chew on my good side.
- B. An analgesic will relieve my pain.
- C. I should use warm mouthwash for oral hygiene.
- D. Taking my carbamazepine will help control my pain.
Correct Answer: B
Rationale: Chronic irritation of cranial nerve V results in trigeminal neuralgia, and it is characterized by intermittent episodes of intense pain of sudden onset on the affected side of the face. The pain is rarely relieved by analgesics. It is recommended that clients chew on the unaffected side and use warm mouthwash for oral hygiene. Medications such as carbamazepine help control the pain of trigeminal neuralgia.
A mother infected with hepatitis B asks the nurse about the possibility of breastfeeding her neonate. Which response by the nurse would be most appropriate?
- A. Yes, breastfeeding is an acceptable option.
- B. No, you should not breastfeed your baby.
- C. Yes, breastfeeding is an acceptable option once your baby is immunized with the hepatitis B vaccine.
- D. Bottled formula is just as nutritious for your baby.
Correct Answer: C
Rationale: Breastfeeding is safe for hepatitis B-positive mothers if the neonate is vaccinated and receives immunoglobulin, reducing transmission risk.
A client diagnosed with chronic obstructive pulmonary disease (COPD) is admitted to the hospital with an exacerbation. Which factor contributed most to the change in client status?
- A. Decreased fat intake
- B. Decreased fluid intake
- C. Sleeping soundly during the night
- D. Anxiety about the upcoming pulmonologist visit
Correct Answer: B
Rationale: The client with exacerbation of COPD has ineffective coughing and excess sputum in the airways. The nurse assesses the client for contributing factors such as dehydration and a lack of knowledge of proper coughing techniques. The reduction of these factors helps limit exacerbations of the disease. Decreased fat intake, sleeping soundly, and anxiety related to scheduled pulmonologist visit are not directly associated with this change in condition.