Nokea
Select the age group that is coupled with an infectious disease that is most common in this age group.
- A. Infants: High bilirubin
- B. Pre-School and School Age Children: Shingles
- C. Young Adults and Teenagers: Sexually transmitted diseases
- D. The Elderly: Malaria
Correct Answer: C
Rationale: Young adults and teenagers are at the highest risk for sexually transmitted diseases due to their sexual activity. High bilirubin is a laboratory finding related to jaundice and not an infectious disease. Shingles is more common in the elderly population, not in pre-school and school-age children. Malaria is not most common in the elderly; it is prevalent in regions with specific mosquito vectors. Therefore, the correct answer is that young adults and teenagers are most commonly associated with sexually transmitted diseases.
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All hospitals and nursing homes are mandated to have the goal of a restraint-free environment. The best way to achieve this goal is to ________________.
- A. ban the use of all restraints under all circumstances
- B. limit restraints to only those situations when falls cannot be prevented
- C. keep all bedside rails up for all patients during nighttime hours
- D. use non-skid socks and sheets to prevent falls from chairs
Correct Answer: B
Rationale: All hospitals and nursing homes are mandated by JCAHO and state departments of health to have the goal of a restraint-free environment. This does not mean that no restraints can ever be used under any circumstances. The goal is to minimize the use of restraints and prioritize other preventive measures. Restraining a patient should only be considered when all other preventive strategies have failed, and the patient is at risk of harm. Therefore, the best approach is to limit the use of restraints to situations where falls cannot be prevented, ensuring that restraints are used as a last resort to maintain patient safety. Choices C and D are not ideal solutions as they do not address the appropriate use of restraints in a restraint-free environment.
A 31-year-old woman who has multiple sclerosis (MS) asks the nurse about risks associated with pregnancy. Which response by the nurse is accurate?
- A. MS symptoms may be worse after the pregnancy
- B. Women with MS frequently have premature labor
- C. MS is associated with an increased risk for congenital defects
- D. Symptoms of MS are likely to become worse during pregnancy
Correct Answer: A
Rationale: After pregnancy, women with MS are at higher risk for exacerbation of symptoms due to the postpartum period. There is no increased risk for congenital defects in infants born to mothers with MS. Symptoms of MS may actually improve during pregnancy, likely due to hormonal changes. MS does not significantly impact the onset of labor. Therefore, the correct response is that MS symptoms may worsen after pregnancy, making option A the accurate answer. Options B, C, and D are incorrect as they do not accurately reflect the risks associated with pregnancy in individuals with MS.
Mr. Freeman has difficulty getting out of bed. The nurse should encourage Mr. Freeman to ______________.
- A. ask for assistance before getting out of bed.
- B. remain in bed because it is safer and he will not fall.
- C. instruct him to stand up quickly from the bed.
- D. lean forward and push up and off the bed.
Correct Answer: A
Rationale: The nurse should encourage Mr. Freeman to use his call bell and ask for assistance before getting out of bed. This can prevent him from falling. Patients should not stay in bed; they should be encouraged to get out of bed as much as possible to prevent complications like pressure ulcers and muscle weakness. Instructing a patient to stand up quickly from the bed is unsafe as it can lead to dizziness and falls. Similarly, leaning forward and pushing off the bed can increase the risk of falls and should be avoided. Asking for assistance is the safest and most appropriate option to ensure patient safety and prevent accidents.
Which of these devices is considered a protective device, rather than a restraint?
- A. A mitten on the hands to prevent scratching
- B. A mitten on the hands to prevent the person from pulling their IV out
- C. A side rail to prevent the patient from falling
- D. A soft wrist restraint to prevent the patient from pulling their IV tubing
Correct Answer: A
Rationale: A mitten on the hands to prevent scratching is considered a protective device because its primary purpose is to protect the patient from harming themselves by scratching. It does not restrict the patient's movement. Choice B, a mitten on the hands to prevent the person from pulling their IV out, is considered a restraint as it limits the patient's movement. Choice C, a side rail to prevent the patient from falling, is also a protective device as it aims to keep the patient safe by providing support and preventing falls. Choice D, a soft wrist restraint to prevent the patient from pulling their IV tubing, is a type of restraint as it restricts the patient's movement to prevent them from interfering with medical equipment.
A patient born in 1955 had hepatitis A infection 1 year ago. According to Centers for Disease Control and Prevention (CDC) guidelines, which action should the nurse include in care when the patient is seen for a routine annual physical exam?
- A. Start the hepatitis B immunization series.
- B. Teach the patient about hepatitis A immune globulin.
- C. Ask whether the patient has been screened for hepatitis C.
- D. Test for anti-hepatitis-A virus immune globulin M (anti-HAV-IgM).
Correct Answer: C
Rationale: The correct action for the nurse to include in care when the patient is seen for a routine annual physical exam, according to CDC guidelines, is to ask whether the patient has been screened for hepatitis C. CDC guidelines recommend screening patients born between 1945 and 1965 for hepatitis C due to the high prevalence of undiagnosed cases in this age group. Starting the hepatitis B immunization series is not necessary as the patient already had hepatitis A infection. Teaching the patient about hepatitis A immune globulin is not indicated in this scenario. Testing for anti-hepatitis-A virus immune globulin M (anti-HAV-IgM) is not needed as the patient has already had hepatitis A.