Legal protection of confidentiality:
- A. extends only to written documentation.
- B. extends to the electronic dissemination of information not identifiable to a specific client.
- C. is important only within the court system.
- D. extends to both written and verbal information.
Correct Answer: D
Rationale: Legal protection of confidentiality extends to both written and verbal information identifiable as individual private health information.
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The most effective nursing strategy to assist a client in recognizing and using personal strength includes:
- A. encouraging the client's self-identification of strengths
- B. promoting the client's active external thinking
- C. listening to the client and providing advice as needed
- D. assisting the client in maintaining an external locus of control
Correct Answer: A
Rationale: Encouraging self-identification of strengths empowers the client to recognize their capabilities, fostering confidence and resilience. External thinking or locus of control may disempower, and advice-giving is less effective than self-discovery.
The nurse should utilize data about which of the following to provide information about the nutritional status of a client being evaluated for malnutrition?
- A. triceps skinfold measurement
- B. fasting blood glucose level
- C. hemoglobin A1c level
- D. serum lipid profile results
Correct Answer: A
Rationale: Objective anthropometric measurements such as triceps skinfold and mid-arm circumference (MAC), along with weight, are usually used to diagnose malnutrition. While all the other choices represent tests that might provide useful information, they also might be affected by variables other than malnutrition.
A 21-year-old college student has just learned that she contracted genital herpes from her sexual partner. After completing the initial history and assessment, the nurse has data concerning areas pertinent to the disease. The data is likely to include all but which of the following?
- A. voiding patterns
- B. characteristics of lesions
- C. vaginal discharge
- D. prior history of varicella
Correct Answer: D
Rationale: The other choices are common reasons for which clients with herpes seek care.
Mrs. Owens is the 81-year-old mother of Jonathan, who is 54 years old. Jonathan has had schizophrenia since he was 16 years old. Which of Mrs. Owens's concerns is likely to predominate?
- A. Will my retirement funds outlast me?
- B. Who will handle my funeral arrangements?
- C. What will become of Jonathan when I am gone?
- D. How can I get Jonathan's physician to talk to me?
Correct Answer: C
Rationale: The mother's most prominent concern is likely to be what becomes of her son after she dies. Choice 1 is important but is not likely to be her most prominent concern. Choice 2 is also not likely to be her primary concern because the welfare of her son with schizophrenia is more important. Choice 4 is incorrect because Mrs. Owens has likely confronted and handled concerns about getting the physician to talk to her after 38 years of managing her son's care.
Which of the following viruses is most likely to be acquired through casual contact with an infected individual?
- A. influenza virus
- B. herpes virus
- C. cytomegalovirus (CMV)
- D. human immunodeficiency virus (HIV)
Correct Answer: A
Rationale: Influenza virus is transmitted through respiratory droplets. Herpes virus is transmitted by direct contact, and HIV is transmitted through blood and body fluids. Cytomegalovirus is an opportunistic infection.