Nokea
An adult who has just been diagnosed with pulmonary tuberculosis asks the nurse how long he will have to be in isolation. What should be included in the nurse's reply?
- A. Isolation is for the duration of the treatment, which is at least 26 weeks.
- B. Isolation is necessary as long as the client has a cough.
- C. When the client has three negative sputum specimens, isolation is discontinued.
- D. When the evening fevers and night sweats subside, isolation is discontinued.
Correct Answer: C
Rationale: Isolation for pulmonary TB ends when three consecutive sputum samples are negative, indicating non-infectiousness, typically before the full 6-month treatment.
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A client who has been treated for syphilis.
In preparing discharge plans for a client who has been treated for syphilis, it is MOST important for the community health nurse to include which of the following information?
- A. Practice restraint of sexual activity.
- B. The practice of safe sex.
- C. Information about Planned Parenthood.
- D. Signs of a secondary infection.
Correct Answer: B
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) not effective in the prevention of transmission of sexually transmitted diseases (2) correct-practice of safe sex, e.g., use of condoms, is primary prevention for transmission of sexually transmitted diseases (3) not as effective in the prevention of transmission of sexually transmitted diseases (4) not as effective in the prevention of transmission of sexually transmitted diseases
A client with a fractured femur has been in Russell's traction for 24 hours. Which nursing action is associated with this therapy?
- A. Check the skin on the sacrum for breakdown
- B. Inspect the pin site for signs of infection
- C. Auscultate the lungs for atelectasis
- D. Perform a neurovascular check for circulation
Correct Answer: D
Rationale: Perform a neurovascular check for circulation. While each of these is an important assessment, the neurovascular integrity check is most associated with this type of traction. Russell's traction is Buck's traction with a sling under the knee.
A client with a hiatal hernia.
A nursing assessment of a client with a hiatal hernia is MOST likely to reveal
- A. a bulge in the lower right quadrant.
- B. pain at the umbilicus radiating down into the groin.
- C. a burning sensation in the midepigastric area each day before lunch.
- D. complaints of awakening at night with heartburn.
Correct Answer: D
Rationale: Strategy: Think about each answer choice. (1) suggests an inguinal hernia (2) suggests an inguinal hernia (3) pain usually does not develop during the day with an empty stomach (4) correct-classic symptom of hiatal hernia associated with reflux
The nurse is transporting a mother and her newborn upon discharge from the hospital. When the nurse is assisting the mother and newborn into the car, the nurse notes that the car is equipped with a front-facing car seat that is in the front seat of the car. Which action is most appropriate for the nurse?
- A. Position the infant in the car seat as positioned.
- B. Explain that a rear-facing car seat is necessary and offer to lend the family a car seat from the hospital for the trip home.
- C. Tell the mother that holding the infant is safer than putting the infant in a front-facing car seat.
- D. Place the car seat in the back seat and position the infant appropriately.
Correct Answer: B
Rationale: Infants require rear-facing car seats in the back seat for safety. Offering a hospital car seat ensures proper transport safety.
A diagnosis of pernicious anemia is made by:
- A. Bone marrow aspiration
- B. Quantitative assay
- C. Weber test
- D. Schilling test
Correct Answer: D
Rationale: The Schilling test diagnoses pernicious anemia by assessing vitamin B12 absorption. Bone marrow aspiration, quantitative assays, or the Weber test (hearing) are not specific to this condition.