Nokea
A nursing assistant states that her five-year-old child has developed chickenpox.
It would be MOST important for the nurse to ask which of the following questions?
- A. Have your other children had chickenpox?'
- B. Does your child have a temperature?'
- C. Have you had the chickenpox?'
- D. Do you have someone to watch your child?'
Correct Answer: C
Rationale: Strategy: 'MOST important' indicates there may be more than one answer that you would like to select. Remember, you can only ask one question. (1) chickenpox spread by direct contact, airborne route; not the most important question (2) fever, malaise, and anorexia occur during first 24 hours; treat with Tylenol (3) correct-need to ascertain if staff has had the disease; if not, VZIG can be given; exclude from patient care from the 10th day after first exposure through the 21st day (28th day if VZIG given) after last exposure (4) important information, but assessing staff is most important
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A client with schizophrenia is receiving Clozaril (clozapine) 150 mg twice a day. An adverse reaction to the medication is:
- A. Photosensitivity
- B. Extreme elevations in temperature
- C. Weight gain
- D. Elevated blood pressure
Correct Answer: C
Rationale: Weight gain is a common adverse reaction to clozapine, often requiring monitoring and lifestyle interventions.
A prenatal client tests positive for chlamydia in her ninth month. She asks why she should be treated since she does not have symptoms. The nurse should tell the client that if she is not treated before delivery, there is a risk of which problem?
- A. Transplacental infection of the fetus
- B. Neonatal ophthalmia
- C. Pregnancy-induced hypertension
- D. Congenital anomalies
Correct Answer: B
Rationale: Untreated chlamydia can cause neonatal conjunctivitis (ophthalmia neonatorum) during vaginal delivery, necessitating treatment to prevent infant complications.
The nurse is caring for a 79-year-old client. Which observation is not normal and should be reported for follow-up?
- A. The client has several brown spots on her cheek and neck.
- B. The client says, 'I move slower than I used to.'
- C. The client is short of breath when walking down the hall.
- D. The client says, 'I have trouble telling the colors of my socks.'
Correct Answer: C
Rationale: Shortness of breath with exertion may indicate cardiovascular or respiratory issues, requiring follow-up. Brown spots, slower movement, and color vision changes are normal aging signs.
The home care nurse is instructing a client recently diagnosed with tuberculosis.
- A. What is the most important instruction for a client with tuberculosis?
- B. During the first two weeks of treatment, the client should cover his mouth and nose when he coughs or sneezes.
- C. It is necessary for the client to wear a mask at all times to prevent transmission of the disease.
- D. The family should support the client to help reduce feeling of low self-esteem and isolation.
- E. The client will be required to take prescribed medication for a duration of 6-9 months.
Correct Answer: D
Rationale: Adherence to a 6-9 month medication regimen is critical to cure tuberculosis and prevent drug resistance. While respiratory precautions, family support, and masks are important, long-term medication compliance is the most essential for treatment success.
The provisions of the law for the Americans with Disabilities Act require nurse managers to
- A. Maintain an environment free from associated hazards
- B. Provide reasonable accommodations for disabled individuals
- C. Make all necessary accommodations for disabled individuals
- D. Consider both mental and physical disabilities
Correct Answer: B
Rationale: The law is designed to permit persons with disabilities access to job opportunities. Employers must evaluate an applicant's ability to perform the job and not discriminate on the basis of a disability. Employers also must make 'reasonable accommodations.'