Nokea
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. Physiological Adaptation
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On the day of surgery, the nurse noted the following laboratory results.
Which one should be reported to the surgeon immediately?
- A. Creatinine level 1.7 mg/dl.
- B. WBC 12,000.
- C. Hemoglobin 12 mg/dl.
- D. Potassium level 5.0 mEq/L.
Correct Answer: B
Rationale: Elevated WBC is a sign of infection, which requires immediate reporting to the surgeon to assess the need to postpone surgery.
A newly diagnosed HIV patient is in your care. The patient has a positive PPD result of 5 mm induration and a normal CXR.
Which of the following represents preferred treatment of this patient?
- A. INH and pyridoxine
- B. IHN and Rifampin
- C. Rifampin and Streptomycin
- D. No pharmacotherapeutic regimen necessary.
Correct Answer: A
Rationale: INH with pyridoxine is the standard treatment for latent TB in HIV patients with a positive PPD.
A male patient with thrombophlebitis is apprehensive about the possibility of a clot reaching his heart, causing sudden death.
The nurse's initial intervention should be to:
- A. Clarify his misconception.
- B. Explain preventive measures.
- C. Teach recognition of early symptoms.
- D. Encourage discussion of the patient's concern.
Correct Answer: A
Rationale: Clarifying that thrombophlebitis clots rarely reach the heart addresses the patient's fear directly.
A client with which of the following conditions is at risk for developing a high ammonia level?
- A. renal failure
- B. psoriasis
- C. lupus
- D. cirrhosis
Correct Answer: D
Rationale: Cirrhosis impairs the liver's ability to metabolize ammonia, leading to elevated levels and risk of hepatic encephalopathy. The other conditions do not directly affect ammonia levels. Reduction of Risk Potential
A 4-year-old child with Down syndrome is admitted to the hospital with pneumonia. She has a heart murmur and appears to be in respiratory distress. Her mother asks why her child has a heart murmur. What is the best nursing response?
- A. Because she has pneumonia, her heart is working harder and causes the murmur.'
- B. Heart murmurs come and go in children. It is not a great concern.'
- C. Because of the pneumonia, her ductus arteriosus is functioning again.'
- D. Heart defects are common in children with Down syndrome. Her illness may make the murmur louder.'
Correct Answer: D
Rationale: Congenital heart defects, like ventricular septal defects, are common in Down syndrome, and pneumonia may amplify a murmur due to increased cardiac workload.