Nokea
A stool culture reveals Shigella. What corollary should the nurse recognize regarding this bacterial infection?
- A. People who have been in contact with the client need to be tested
- B. Shigella is an airborne infection
- C. Shigella is a bacteria sometimes found in stagnant water
- D. The nurse should wear a one-way breathing apparatus when giving client care
Correct Answer: C
Rationale: Shigella is transmitted via the oral-fecal route, often through contaminated water or food, including stagnant water, requiring hand washing and gloves for prevention.
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A successful resolution of the nursing diagnosis Negative Self-Concept (related to unrealistic self-expectations) is when the client can:
- A. report a positive self-concept.
- B. identify negative thoughts.
- C. recognize positive thoughts.
- D. give one positive cue with each negative cue
Correct Answer: A
Rationale: The correct answer is to 'report a positive self-concept.' The problem statement is Negative Self-Concept, so the goal is for the client to achieve a positive self-concept. This involves helping the client recognize their worth and strengths. Choices B, C, and D do not directly address the resolution of Negative Self-Concept. Identifying negative thoughts (B) is a step towards improvement but does not represent a successful resolution. Recognizing positive thoughts (C) is positive but not the primary goal in addressing Negative Self-Concept. 'Give one positive cue with each negative cue' (D) is not as comprehensive as achieving an overall positive self-concept.
During the work phase of the nurse-client relationship, the client says to her primary nurse, "You think that I could walk if I wanted to, don't you?"? What is the best response by the nurse?
- A. "Yes, if you really wanted to, you could."?
- B. "Tell me why you're concerned about what I think."?
- C. "Do you think you could walk if you wanted to?"?
- D. "I think you're unable to walk now, whatever the cause."?
Correct Answer: D
Rationale: This response answers the question honestly and nonjudgmentally and helps to preserve the client's self-esteem. The nurse acknowledges the client's current inability to walk without attributing it to the client's desire. Choice A provides a positive but unrealistic statement that may diminish the client's self-esteem by implying a lack of effort. Choice B deflects the client's question and does not address the underlying concern. Choice C may increase the client's anxiety by suggesting unresolved psychological conflicts related to walking.
The physician orders the antibiotics ampicillin (Omnipen) and gentamicin (Garamycin) for a newly admitted client with an infection. The nurse should:
- A. administer both medications simultaneously.
- B. give the medications sequentially, and flush well between them.
- C. ask the physician or pharmacy which medication to give first and how long to wait before giving the other drug.
- D. start one medication now and begin the other medication in 2-4 hours.
Correct Answer: B
Rationale: A client with an infection needs both antibiotics as soon as possible. However, the pH of ampicillin is 8-10, and the pH of gentamicin is 3-5.5, making them incompatible when given together. Flushing well between drugs is necessary to prevent interaction. Choice C is incorrect because the nurse, not the physician or pharmacy, should determine the correct administration sequence. Consulting with the pharmacist is appropriate if uncertain. Choice D is incorrect because delaying the second medication by several hours can slow the treatment of the client's infection, as both antibiotics are needed promptly to address the infection effectively. Therefore, the correct action is to give the medications sequentially and flush well between them to prevent any potential interactions.
Implementing counseling by the nurse specialist for the raped victim represents:
- A. assessment.
- B. crisis intervention.
- C. empathetic concern.
- D. unwarranted intrusion.
Correct Answer: B
Rationale: Choice B, crisis intervention, is the correct answer. Counseling by a nurse specialist in a rape crisis situation is a form of crisis intervention, which is part of the Crisis Intervention Model. It aims to provide immediate support and help the victim cope with the traumatic event. Empathetic concern (Choice C) is important but refers more to the nurse's attitude rather than the specific action described. Assessment (Choice A) typically involves gathering information and may have already been done before counseling. Unwarranted intrusion (Choice D) is not applicable here as the counseling is provided to support the victim in a professional and caring manner.
Which of the following actions should a nurse take first for a client who has just vomited 300 cc of bright red blood?
- A. Document the vomiting.
- B. Increase the IV fluids.
- C. Get a complete blood count.
- D. Check the blood pressure.
Correct Answer: D
Rationale: The blood pressure should be checked first for a client who has just vomited 300 cc of bright red blood, to determine whether the client is hypotensive. The other actions can be taken later.