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Nurse reviewing CDC's immunization recommendations with parents of adolescent. Which should nurse include in this discussion? (Select all that apply.)
- A. Rotavirus
- B. Varicella
- C. Herpes zoster
- D. HPV
- E. Seasonal influenza
Correct Answer: B,D,E
Rationale: The correct answers are B, D, and E. Varicella (B) vaccine is recommended for adolescents who haven't been vaccinated before. HPV (D) vaccine is crucial for preventing certain types of cancers. Seasonal influenza (E) vaccine helps protect against the flu, which can be severe. Rotavirus (A) vaccine is typically given to infants, not adolescents. Herpes zoster (C) vaccine is for adults over 50. No information is given for choices F and G.
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Nurse counseling young adult who describes having difficulty dealing with several issues. Which problem should nurse identify as priority for further assessment & intervention?
- A. I have my own apartment now, but it's not easy living away from my parents
- B. It's been so stressful for me to even think about having my own family
- C. I don't even know who I am yet, & now I'm supposed to know what to do
- D. My girlfriend is pregnant, & I don't think I have what it takes to be a good father
Correct Answer: C
Rationale: The correct answer is C because the young adult expressing uncertainty about their own identity indicates a potential issue with self-awareness and self-esteem, which are foundational for healthy development. This can impact decision-making and overall well-being. Choices A, B, and D focus on external factors (living situation, family stress, and impending fatherhood) that can be addressed once the individual's self-identity is better understood. Prioritizing self-discovery and self-acceptance can lead to more effective coping mechanisms and decision-making skills for handling other stressors.
Nurse educator presenting on basic first aid for new home health nurses. She evaluates teaching as effective when a new nurse states that a client who has heat stroke will have which of the following?
- A. Hypotension
- B. Bradycardia
- C. Clammy skin
- D. Bradypnea
Correct Answer: A
Rationale: The correct answer is A: Hypotension. Heat stroke leads to severe dehydration and vasodilation, causing a drop in blood pressure (hypotension). Bradycardia (B), clammy skin (C), and bradypnea (D) are not characteristic of heat stroke. Bradycardia is a slow heart rate, while heat stroke typically causes tachycardia. Clammy skin is more indicative of shock or hypoglycemia, not heat stroke. Bradypnea is slow breathing, but heat stroke usually leads to rapid, shallow breathing. Therefore, hypotension is the most appropriate choice as it aligns with the physiological response to heat stroke.
Nurse is giving presentation about accident prevention to group of parents & toddlers. Which strategies should nurse include? (Select all that apply.)
- A. Keep toxic agents in locked cabinets
- B. Keep toilet seats up
- C. Turn pot handles toward back of stove
- D. Place safety gates across stairways
- E. Make sure balloons are fully inflated
Correct Answer: A,C,D
Rationale: The correct answers are A, C, and D. A) Keeping toxic agents in locked cabinets prevents toddlers from accessing harmful substances. C) Turning pot handles toward the back of the stove prevents toddlers from accidentally pulling them down. D) Placing safety gates across stairways prevents toddlers from falling down stairs. B) Keeping toilet seats up increases the risk of toddlers falling in. E) Having balloons fully inflated poses a choking hazard. In summary, choices A, C, and D are important strategies for accident prevention, while choices B and E can actually increase risks for toddlers.
Nurse talking with adolescent who describes having difficulty dealing with several issues. Which problem should nurse identify as priority for further assessment & intervention?
- A. I kind of like this girl in my class, but she doesn't like me back like that.
- B. I like hanging out with the guys in the science club, but the jocks pick on them.
- C. I just don't seem to be good at anything. I can't play sports at all.
- D. My dad wants me to be a lawyer like him, but I don't want to learn all that stuff
Correct Answer: C
Rationale: The correct answer is C because the adolescent's self-perception of not being good at anything can indicate low self-esteem and potential mental health concerns. This could impact their overall well-being and ability to cope with various stressors. Identifying and addressing self-esteem issues is crucial for their emotional development. Choices A, B, and D are not immediate priorities as they involve interpersonal relationships and career aspirations, which are important but not as urgent as addressing the adolescent's self-perception and mental health.
Nurse wearing sterile gloves in prep for performing sterile procedure. Which of following objects may nurse touch without breaching sterile technique?
- A. Bottle containing sterile solution
- B. Edge of sterile drape at base of field
- C. Inner wrapping of an item on sterile field
- D. Irrigation syringe on sterile field
- E. 1 gloved hand with the other gloved hand
Correct Answer: C,D,E
Rationale: The correct choices are C, D, and E. The nurse can touch the inner wrapping of an item on the sterile field because it is considered sterile. The nurse can touch the irrigation syringe on the sterile field as long as it is also considered sterile and part of the field. The nurse can also touch one gloved hand with the other gloved hand, as the gloves are considered sterile. Choices A and B are incorrect because touching the bottle or the edge of the drape would breach sterile technique.