Teaching the client with gonorrhea how to prevent reinfection and further spread is an example of:
- A. primary prevention.
- B. secondary prevention.
- C. tertiary prevention.
- D. primary health care prevention.
Correct Answer: B
Rationale: Secondary prevention targets the reduction of disease prevalence and disease morbidity through early diagnosis and treatment.
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A client comes to the clinic for assessment of his physical status and guidelines for starting a weight-reduction diet. The client's weight is 216 pounds and his height is 66 inches. The nurse identifies the BMI (body mass index) as:
- A. within normal limits, so a weight-reduction diet is unnecessary.
- B. lower than normal, so education about nutrient-dense foods is needed.
- C. indicating obesity because the BMI is 35.
- D. indicating overweight status because the BMI is 27.
Correct Answer: C
Rationale: Obesity is defined by a BMI of 30 or more with no co-morbid conditions. It is calculated by utilizing a chart or nomogram that plots height and weight. This client's BMI is 35, indicating obesity. Goals of diet therapy are aimed at decreasing weight and increasing activity to healthy levels based on a client's BMI, activity status, and energy requirements.
What do the following ABG values indicate: pH 7.38, PO2 78 mmHg, PCO2 36 mmHg, and HCO3 24 mEq/L?
- A. metabolic alkalosis
- B. homeostasis
- C. respiratory acidosis
- D. respiratory alkalosis
Correct Answer: B
Rationale: These ABG values are within normal limits. Choices A, C, and D are incorrect because the ABG values indicate none of these acid-base disturbances.
Which of the following observations is most important when assessing a client's breathing?
- A. presence of breathing and pulse rate
- B. breathing pattern and adequacy of breathing
- C. presence of breathing and adequacy of breathing
- D. patient position and adequacy of breathing
Correct Answer: C
Rationale: Ensuring the presence and adequacy of breathing is critical, as adequate oxygenation is essential for life. Pulse rate and position are secondary considerations.
Laboratory tests reveal the following electrolyte values for Mr. Smith: Na 135 mEq/L, Ca 8.5 mg/dL, Cl 102 mEq/L, and K 2.0 mEq/L. Which of the following values should the nurse report to the physician because of its potential risk to the client?
- A. Ca
- B. K
- C. Na
- D. Cl
Correct Answer: B
Rationale: A potassium level of 2.0 mEq/L is critically low (normal 3.5-5.5 mEq/L), risking cardiac arrhythmias, and should be reported immediately.
A client begins a regimen of chemotherapy. Her platelet counts falls to 98,000. Which action is least likely to increase the risk of hemorrhage?
- A. Test all excreta for occult blood.
- B. Use a soft toothbrush or foam cleaner for oral hygiene.
- C. Implement reverse isolation.
- D. Avoid IM injections.
Correct Answer: C
Rationale: Reverse isolation does not affect the risk of hemorrhage.