Nokea
Nurse is teaching young adult about health promotion & illness prevention. Which client statement indicates understanding?
- A. I already had my immunizations as a child, so I'm protected in that area.
- B. It's important to schedule routine healthcare visits even if I'm feeling well
- C. If I'm having any discomfort, I'll just go to an urgent care center
- D. If I'm feeling stressed, I will remind myself that this is something I should expect
Correct Answer: B
Rationale: The correct answer is B: It's important to schedule routine healthcare visits even if I'm feeling well. This statement indicates understanding of health promotion and illness prevention as it emphasizes the importance of preventive care and early detection of potential health issues. By attending routine healthcare visits, the individual can monitor their health status, receive necessary screenings, and address any underlying health concerns before they escalate.
Choice A is incorrect because having immunizations as a child does not provide lifelong protection against all diseases. Choice C is incorrect as urgent care centers are typically for urgent medical needs, not routine preventive care. Choice D is incorrect as stress management is important, but it does not directly relate to health promotion and illness prevention.
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When entering client's room to change dressing
- A. nurse notes client is coughing & sneezing. When preparing sterile field
- B. it's important the nurse...
- C. Keep sterile field at least 6 ft away from client's bedside
- D. Instruct client to not cough/sneeze during dressing change
- E. Place mask on client to limit spread of microorganisms into surgical wound
Correct Answer: C
Rationale: The correct answer is C because keeping the sterile field at least 6 feet away from the client's bedside helps to maintain its integrity and prevent contamination. Placing the field further away reduces the risk of microorganisms reaching it during the dressing change procedure. Choice A is incorrect as the nurse should address the client's coughing and sneezing before proceeding with the dressing change. Choice B is vague and does not directly relate to maintaining sterility. Choice D is ineffective as instructing the client to stop coughing or sneezing is unrealistic. Choice E, while a good practice in general, does not directly address the maintenance of the sterile field.
Nurse talking with adolescent who describes having difficulty dealing with several issues. Which problem should nurse identify as priority for further assessment & intervention?
- A. I kind of like this girl in my class, but she doesn't like me back like that.
- B. I like hanging out with the guys in the science club, but the jocks pick on them.
- C. I just don't seem to be good at anything. I can't play sports at all.
- D. My dad wants me to be a lawyer like him, but I don't want to learn all that stuff
Correct Answer: C
Rationale: The correct answer is C because the adolescent's self-perception of not being good at anything can indicate low self-esteem and potential mental health concerns. This could impact their overall well-being and ability to cope with various stressors. Identifying and addressing self-esteem issues is crucial for their emotional development. Choices A, B, and D are not immediate priorities as they involve interpersonal relationships and career aspirations, which are important but not as urgent as addressing the adolescent's self-perception and mental health.
Nurse is completing discharge teaching to client with COPD. Client verbalizes understanding of orthopneic position when he states, 'When I have difficulty breathing at night, I will...'
- A. Lie on my back with head & shoulders elevated on a pillow
- B. Lie flat on my stomach with head to one side
- C. Sit on side of my bed & rest my arms over pillows on top of my raised bedside table
- D. Lie on my side with my weight on my hips & shoulder with my arms flexed in front of me
Correct Answer: C
Rationale: The correct answer is C: Sit on side of my bed & rest my arms over pillows on top of my raised bedside table. This position, known as orthopneic position, helps improve breathing by allowing the chest to expand fully, making it easier to take deep breaths. Sitting on the side of the bed and resting arms over pillows on a raised table helps to reduce the work of breathing.
A: Lie on my back with head & shoulders elevated on a pillow - This position may not provide as much relief in breathing as the orthopneic position.
B: Lie flat on my stomach with head to one side - This position can actually make breathing more difficult for someone with COPD.
D: Lie on my side with my weight on my hips & shoulder with my arms flexed in front of me - This position may not be as effective in improving breathing compared to the orthopneic position.
By choosing option C, the client can effectively manage breathing difficulties associated with
Nurse is caring for client who presents with linear clusters of fluid-containing vesicles with some crusting. Which should nurse suspect?
- A. Allergic reaction
- B. Ringworm
- C. Systemic lupus erythematosus
- D. Herpes zoster
Correct Answer: D
Rationale: The correct answer is D: Herpes zoster. The description of linear clusters of fluid-containing vesicles with some crusting is characteristic of herpes zoster, also known as shingles. This condition is caused by the reactivation of the varicella-zoster virus, which initially causes chickenpox. The linear distribution along a dermatome is a key feature of herpes zoster. Allergic reaction (A) typically presents with generalized rash and itching, not linear clusters of vesicles. Ringworm (B) presents as circular, scaly lesions, not linear clusters of vesicles. Systemic lupus erythematosus (C) is an autoimmune disease that presents with a variety of symptoms, but not linear clusters of vesicles.
Security officer reviewing actions to take in event of bomb threat by phone. Which statement indicates proper understanding of procedure?
- A. I will get the caller off the phone ASAP to alert the staff
- B. I will use overhead paging to alert entire facility
- C. I will not ask any questions & just let the caller talk
- D. I will listen for background noises
Correct Answer: D
Rationale: The correct answer is D because listening for background noises can provide crucial information to identify the location or nature of the threat. By actively listening, the security officer can gather valuable details without alerting the caller. Choice A is incorrect because abruptly ending the call may prevent gathering important information. Choice B is incorrect as overhead paging may cause panic. Choice C is incorrect as asking questions can elicit useful details.