The nurse hears another staff member talking in a crowded elevator about a client on the unit. The client is identified by name and details of illness. What action should the practical nurse take at this time?
- A. Report the behavior to the head nurse
- B. Report the behavior if it happens again
- C. Interrupt the conversation in the elevator
- D. Speak to the staff member when he/she gets off the elevator
Correct Answer: D
Rationale: Speaking to the staff member privately after the elevator ride addresses the HIPAA violation discreetly, promoting education and correction without immediate escalation.
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A client is prescribed long-term pharmacologic therapy with hydroxychloroquine to treat systemic lupus erythematosus. The nurse should reinforce teaching about which intervention related to the drug's adverse effects?
- A. Have an ophthalmologic examination every 6 months
- B. Take the medication on an empty stomach
- C. Take vitamin D and calcium supplements
- D. Wear a MedicAlert bracelet
Correct Answer: A
Rationale: Hydroxychloroquine can cause retinal toxicity. Regular ophthalmologic exams every 6 months are essential to monitor for early signs of retinal damage.
The nurse is planning care for a client who has a hearing impairment. Which action will likely help the most with communication?
- A. Repeat everything twice.
- B. Speak loudly.
- C. Speak slowly and clearly.
- D. Use gestures.
Correct Answer: C
Rationale: Speaking slowly and clearly enhances comprehension for hearing-impaired clients. Repeating, shouting, or gestures may confuse or overwhelm.
During the initial interview, the client reports that she has a lesion on the perineum. Further investigation reveals a small blister on the vulva that is painful to touch. The nurse is aware that the most likely source of the lesion is:
- A. Syphilis
- B. Herpes
- C. Gonorrhea
- D. Condylomata
Correct Answer: B
Rationale: A lesion that is painful is most likely a herpetic lesion. A chancre lesion associated with syphilis is not painful, so answer A is incorrect. Gonorrhea does not present as a lesion but is exhibited by a yellow discharge, so answer C is incorrect. Condylomata lesions are painless warts, so answer D is incorrect.
The nurse is caring for a client with liver cirrhosis. Which of the following assessment findings would warrant immediate follow up?
- A. Black, tarry stool
- B. Bright red-streaked stool
- C. Light gray clay-colored stool
- D. Small, dry, rocky stool
Correct Answer: A
Rationale: Black, tarry stool (melena) indicates upper gastrointestinal bleeding, a serious complication in cirrhosis due to portal hypertension or varices, requiring immediate intervention.
The nurse cares for a child with bed bug bites. Which parent statement indicates that further teaching is required?
- A. I need to have the entire house treated by pest control to ensure the bed bugs are gone.
- B. I should concentrate on alleviating scratching as it can cause further complications.
- C. My other family members and pets are at risk of bed bug bites.
- D. This must have happened because I did not wash the bed sheets this week.
Correct Answer: D
Rationale: Bed bug infestations are not caused by unwashed sheets but by exposure to infested environments. This misconception indicates a need for further teaching about bed bug transmission and prevention.
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