Nokea
The nurse observes the student nurse enter wearing a gown, gloves, and a mask.
The nurse determines that the precautions are correct if the student nurse is caring for which of the following clients?
- A. An infant diagnosed with respiratory syncytial virus.
- B. A young child with a wound infected with S aureus.
- C. A teenager diagnosed with toxic shock syndrome.
- D. A teenager diagnosed with rubella (German measles).
Correct Answer: D
Rationale: Strategy: Determine the precautions required for each disease. (1) requires contact precautions, no mask (2) requires contact precautions, no mask (3) standard precautions (4) correct-droplet precautions used for organisms that can be transmitted by face-to-face contact, door may remain open
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An adult is being worked up for possible pulmonary tuberculosis. The nurse knows that which test is most conclusive for the diagnosis of tuberculosis?
- A. Intradermal skin test
- B. Chest x-ray
- C. Sputum examination
- D. Computed tomography (CT) scan
Correct Answer: C
Rationale: Sputum examination for acid-fast bacilli is the gold standard for confirming tuberculosis, unlike skin tests (screening), x-rays (supportive), or CT (non-specific).
Following a stroke, a client is found to have receptive aphasia. This finding is consistent with damage to:
- A. The frontal lobe
- B. The parietal lobe
- C. The temporal lobe
- D. The occipital lobe
Correct Answer: C
Rationale: Receptive aphasia, difficulty understanding language, is associated with damage to the temporal lobe, specifically Wernicke's area.
A 15-month-old child has just been diagnosed with sickle cell anemia. The mother is pregnant and asks if the child she is carrying will also have sickle cell anemia. She says that neither she nor her husband has sickle cell anemia. The nurse's reply should be based on which understanding?
- A. There is a 50% chance that each child they have will have sickle cell anemia.
- B. The chance of having another child with sickle cell anemia is 1 in 4.
- C. Parents do not usually have two children in a row with sickle cell anemia.
- D. If the child is a boy, there is a 50% chance that he will have sickle cell anemia.
Correct Answer: B
Rationale: Sickle cell anemia is autosomal recessive; if both parents are carriers (trait), there's a 25% (1 in 4) chance per child of inheriting the disease, independent of gender or prior children.
The nurse is teaching unlicensed personnel about preventing the spread of disease in the health care environment. The nurse knows that the personnel understand when they state that which is the most important way to prevent the spread of disease?
- A. Isolating infected clients
- B. Consistently washing hands
- C. Wearing a gown when there is a question of a client with a questionable disease
- D. Wearing gloves whenever giving care
Correct Answer: B
Rationale: Hand washing is the most effective way to prevent disease transmission, breaking the chain of infection in healthcare settings.
The nurse is caring for a client who had a myocardial infarction yesterday and received alteplase (tPA). The client's spouse asks the nurse why that medication was given. What should the nurse include when replying?
- A. Alteplase (tPA) is given to relieve the pain of a heart attack.
- B. Alteplase (tPA) dissolves the clot that is blocking a coronary artery.
- C. Alteplase (tPA) prevents new clots from forming and existing clots from getting bigger.
- D. Alteplase (tPA) helps the heart muscle to repair itself.
Correct Answer: B
Rationale: Alteplase (tPA) is a thrombolytic drug and dissolves the clot that is blocking a coronary artery. It does not relieve pain, prevent new clots from forming, or help the heart muscle to heal.