Nokea
A patient has been diagnosed with erectile dysfunction; the cause has been determined to be psychogenic. The patients interdisciplinary plan of care should prioritize which of the following interventions?
- A. Penile implant
- B. PDE-5 inhibitors
- C. Physical therapy
- D. Psychotherapy
Correct Answer: D
Rationale: The correct answer is D: Psychotherapy. In the case of psychogenic erectile dysfunction, the underlying cause is psychological rather than physical. Psychotherapy helps address the mental health factors contributing to the condition, such as anxiety or relationship issues. It can help the patient understand and manage their emotions, thoughts, and behaviors related to the dysfunction. Penile implant (A) and PDE-5 inhibitors (B) are more appropriate for physical causes of erectile dysfunction. Physical therapy (C) focuses on musculoskeletal conditions and would not be effective for psychogenic causes.
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The nurse is preparing to check the gastric aspirate for pH. Which equipment will the nurse obtain?
- A. 10-mL Luer-Lok syringe
- B. Asepto syringe
- C. Sterile gloves
- D. Double gloves
Correct Answer: A
Rationale: The correct answer is A: 10-mL Luer-Lok syringe. The nurse should use this syringe to obtain a gastric aspirate for pH testing because it allows for accurate measurement of the aspirate volume. Asepto syringe (B) is not suitable for this purpose as it is not designed for accurate measurement. Sterile gloves (C) and double gloves (D) are not equipment used specifically for obtaining gastric aspirate for pH testing. Sterile gloves are used for infection control, and double gloves are used for additional protection during procedures.
A nurse is reviewing urinary laboratory results.Which finding will cause the nurse to follow up?
- A. Protein level of 2 mg/100 mL
- B. Urine output of 80 mL/hr
- C. Specific gravity of 1.036
- D. pH of 6.4
Correct Answer: A
Rationale: The correct answer is A because a protein level of 2 mg/100 mL in urine indicates proteinuria, which can be a sign of kidney dysfunction or other underlying health issues. The nurse should follow up to assess further for possible kidney disease or other conditions.
Choice B is not a cause for concern as a urine output of 80 mL/hr is within the normal range.
Choice C indicates concentrated urine, which may be due to dehydration but does not necessarily require immediate follow-up.
Choice D is within the normal range for urine pH and does not typically warrant immediate follow-up.
A patient with HIV will be receiving care in the home setting. What aspect of self-care should the nurse emphasize during discharge education?
- A. Appropriate use of prophylactic antibiotics
- B. Importance of personal hygiene
- C. Signs and symptoms of wasting syndrome
- D. Strategies for adjusting antiretroviral dosages
Correct Answer: B
Rationale: The correct answer is B: Importance of personal hygiene. Maintaining good personal hygiene is crucial for patients with HIV to prevent infections. This includes regular handwashing, oral care, and bathing. By emphasizing personal hygiene, the nurse can help the patient reduce the risk of opportunistic infections. Prophylactic antibiotics (choice A) are important but should be prescribed by the healthcare provider. Signs and symptoms of wasting syndrome (choice C) are significant, but focusing on prevention through hygiene is more practical. Adjusting antiretroviral dosages (choice D) is the responsibility of the healthcare provider, not the patient.
A nurse would identify that a colleague needs additional instruction on standard precautions when the colleague exhibits which of the following behaviors?
- A. The nurse wears face protection, gloves, and a gown when irrigating a wound.
- B. The nurse washes the hands with a waterless antiseptic agent after removing a pair of soiled gloves.
- C. The nurse puts on a second pair of gloves over soiled gloves while performing a bloody procedure.
- D. The nurse places a used needle and syringe in the puncture-resistant container without capping the needle.
Correct Answer: C
Rationale: The correct answer is C because putting on a second pair of gloves over soiled gloves during a procedure violates standard precautions by increasing contamination risk. Here's the rationale:
1. Standard precautions require removing soiled gloves before putting on new ones to prevent cross-contamination.
2. Wearing multiple gloves increases the risk of tearing and exposure to pathogens.
3. This behavior shows a lack of understanding of proper infection control practices.
Summary of other choices:
A: Wearing face protection, gloves, and a gown when irrigating a wound is a correct practice.
B: Washing hands with waterless antiseptic after removing soiled gloves is correct.
D: Placing a used needle and syringe in a puncture-resistant container without capping the needle is incorrect, but not as severe as choice C.
A nurse is assessing the skin integrity of a patient who has AIDS. When performing this inspection, the nurse should prioritize assessment of what skin surfaces?
- A. Perianal region and oral mucosa
- B. Sacral region and lower abdomen
- C. Scalp and skin over the scapulae
- D. Axillae and upper thorax
Correct Answer: A
Rationale: The correct answer is A: Perianal region and oral mucosa. In patients with AIDS, these areas are more prone to opportunistic infections due to decreased immune function. The perianal region can be affected by conditions like anal warts or herpes, while the oral mucosa can develop oral thrush or other oral infections. By prioritizing assessment of these areas, the nurse can promptly identify any potential issues and initiate appropriate interventions.
Choice B: Sacral region and lower abdomen are not typically high-risk areas for skin integrity issues in AIDS patients.
Choice C: Scalp and skin over the scapulae are not commonly affected by opportunistic infections related to AIDS.
Choice D: Axillae and upper thorax are not as commonly affected as the perianal region and oral mucosa in AIDS patients.