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The following data collection findings could indicate to the nurse that the patient has a hearing loss, EXCEPT:
- A. Patient's face is relaxed during conversation.
- B. Patient speaks in a very loud voice.
- C. Patient turns toward person speaking.
- D. Patient is withdrawn.
Correct Answer: A
Rationale: A relaxed face during conversation is not typically indicative of hearing loss. In fact, individuals with hearing loss may exhibit signs such as speaking loudly (Choice B), turning toward the person speaking (Choice C), and feeling withdrawn (Choice D) due to difficulty in hearing and understanding conversations. The act of speaking loudly may be an attempt to compensate for the perceived hearing loss, while turning toward the speaker is a common strategy to better hear and lip-read. Withdrawal can result from the frustration and isolation caused by the inability to fully engage in conversations. Ultimately, a relaxed face during conversation is less likely to be a red flag for hearing loss compared to the other choices provided.
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A patient who is being tested for HIV asks what tests are used. The nurse would correct in stating that the tests used to confirm HIV infection are which of the following?
- A. CD 4+ cell count and thymus function.
- B. ELISA and Western Blot
- C. B-cell and T-cell count.
- D. CD 4+, viral load, and ELISA
Correct Answer: B
Rationale: ELISA (Enzyme-Linked Immunosorbent Assay) and Western Blot are the two main tests used to confirm HIV infection. ELISA is typically the first test performed to detect HIV antibodies in the blood. If the ELISA test is positive, the Western Blot test is then used to confirm the presence of HIV antibodies and differentiate between HIV-1 and HIV-2 antibodies. Both tests are highly sensitive and specific in diagnosing HIV infection. Other tests like CD4+ count and viral load are used to monitor disease progression but are not used primarily to confirm HIV infection.
Sexual abuse should be considered in children who have behavioral problems, although no behavior is pathognomonic. Which of the following behavior should raise the suspicion of sexual abuse?
- A. aggressive
- B. obsessive-compulsive
- C. dissociative
- D. hypersexuality
Correct Answer: D
Rationale: Hypersexuality in children is highly unusual and strongly indicative of possible sexual abuse, as it reflects exposure to inappropriate sexual content or experiences.
A 2-year-old male child has an asymptomatic right flank mass discovered incidentally by the mother while bathing. Suspicion of Wilms tumor is raised. Of the following, the LEAST likely investigation to be performed in this child is
- A. plain abdominal radiography
- B. computerized tomography (CT) scan of the abdomen
- C. CT scan of the chest
- D. biopsy of the mass
Correct Answer: D
Rationale: Biopsy is generally avoided in suspected Wilms tumor to prevent upstaging the disease.
A Jewish client has been diagnosed with ulcerative colitis. A nursing diagnosis appropriate for a client who has ulcerative colitis is:
- A. abdominal pain related to decreased peristalsis
- B. diarrhea related to hyperosmolar intestinal contents
- C. fluid volume excess related to increase water absorption by intestinal mucosa
- D. activity intolerance related to fatigue
Correct Answer: A
Rationale: Among the given choices, the nursing diagnosis appropriate for a client with ulcerative colitis is "abdominal pain related to decreased peristalsis." Ulcerative colitis is a chronic inflammatory bowel disease that directly affects the lining of the colon and rectum, leading to symptoms such as abdominal pain, diarrhea, and bloody stool. Decreased peristalsis occurs in patients with ulcerative colitis, resulting in abdominal pain due to inflammation and irritation of the intestines. This pain is a common symptom experienced by individuals with ulcerative colitis and can significantly impact their quality of life. Therefore, addressing the client's abdominal pain is crucial in providing effective nursing care for someone diagnosed with ulcerative colitis.
The nurse is taking a sexual history on an adolescent girl. Which is the best way to determine whether she is sexually active?
- A. Ask her, "Are you sexually active?"
- B. Ask her, "Are you having sex with anyone?"
- C. Ask her, "Are you having sex with a boyfriend?"
- D. Ask both the girl and her parent whether she is sexually active.
Correct Answer: A
Rationale: The best way to determine whether an adolescent girl is sexually active is to ask her directly, "Are you sexually active?" This question is concise, clear, and non-judgmental, allowing the girl to provide a straightforward answer. It is important to create a safe and open environment for discussing sexual health, and using direct language helps ensure accurate communication. Asking about specific partners (options B and C) may lead to confusion or misinterpretation, and involving the parent (option D) without the girl's consent may violate her privacy and autonomy. Therefore, direct communication with the adolescent herself is the most appropriate approach to gather information about her sexual activity.