Nokea
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
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The nurse is caring for a client with a history of chronic pain.
- A. Which intervention is most effective for managing chronic pain?
- B. Administer analgesics as needed only.
- C. Encourage participation in a pain management program.
- D. Restrict physical activity to reduce pain.
- E. Apply ice packs to the painful area.
Correct Answer: B
Rationale: A pain management program (e.g., cognitive-behavioral therapy, physical therapy) addresses chronic pain holistically, improving function and coping. PRN analgesics are less effective long-term, activity is encouraged, and ice is condition-specific.
The nurse is caring for an adult who is admitted in right heart failure. Which observation is most consistent with this condition?
- A. Distended neck veins
- B. Facial edema
- C. Renal failure
- D. Constipation
Correct Answer: A
Rationale: Right heart failure causes systemic venous congestion, leading to distended neck veins due to increased jugular venous pressure. Facial edema, renal failure, and constipation are less specific to right heart failure.
While a client is receiving TPN, it is MOST important for the nurse to monitor
- A. vital signs and level of consciousness.
- B. arterial blood gases and liver enzymes.
- C. serum glucose and electrolytes.
- D. skin turgor and daily weights.
Correct Answer: C
Rationale: TPN can cause hyperglycemia and electrolyte imbalances, making serum glucose and electrolyte monitoring critical. Options A, B, and D are less specific.
A client who is receiving a blood transfusion experiences a hemolytic reaction. The nurse would anticipate which of the following assessment findings?
- A. Hypotension, backache, low back pain, fever.
- B. Wet breath sounds, severe shortness of breath.
- C. Chills and fever occurring about an hour after the infusion started.
- D. Urticaria, itching, respiratory distress.
Correct Answer: A
Rationale: signs and symptoms of a hemolytic reaction include chills, headache, backache, dyspnea, cyanosis, chest pains, tachycardia, and hypotension
Which of the following laboratory results would suggest to the emergency room nurse that a client admitted after a severe motor vehicle crash is in acidosis?
- A. Hemoglobin 15 gm/dl
- B. Chloride 100 mEq/L
- C. Sodium 130 mEq/L
- D. Carbon dioxide 20 mEq/L
Correct Answer: D
Rationale: Serum carbon dioxide is an indicator of acid-base status. This finding would indicate acidosis.