Nokea
The nurse is caring for a client diagnosed with syphilis. The client presents with a widespread, symmetric maculopapular rash on the palms and soles. The nurse understands that the client is in which stage of the infection?
- A. primary syphilis
- B. secondary syphilis
- C. early latent syphilis
- D. latent phase syphilis
Correct Answer: B
Rationale: A maculopapular rash on palms and soles is characteristic of secondary syphilis, following the primary chancre.
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The nurse is evaluating a hypertensive client's understanding of dietary modifications to control the disease process. The nurse determines that the client's understanding is satisfactory if the client made which meal selections?
- A. Corned beef, fresh carrots, boiled potato
- B. Hot dog on a bun, sauerkraut, baked beans
- C. Turkey, baked potato, salad with oil and vinegar
- D. Scallops, French fries, salad with bleu cheese dressing
Correct Answer: C
Rationale: Hypertensive clients should avoid high-sodium foods like corned beef, hot dogs, sauerkraut, scallops, French fries, and bleu cheese dressing. Turkey, baked potato, and salad with oil and vinegar are low in sodium, indicating correct dietary understanding.
A client at the family planning clinic requests a prescription for oral contraceptives from the nurse who is performing an assessment. After reviewing the client's chart, the nurse determines that oral contraceptives are contraindicated because of which documented item? (Refer to chart.)
- A. Has renal calculi
- B. Blood pressure: 108 / 72mmHg
- C. Had thrombotic stroke at age 35 years
- D. Apical heart rate: 72 beats/min
Correct Answer: C
Rationale: Oral contraceptives are contraindicated in women with a history of thrombophlebitis and thromboembolic disorders; cardiovascular or cerebrovascular diseases (including stroke [brain attack]); any estrogendependent cancer or breast cancer, or benign or malignant liver tumors; impaired liver function; hypertension; or diabetes mellitus with vascular involvement. Adverse effects of oral contraceptives include increased risk of superficial and deep vein thrombosis, pulmonary embolism, thrombotic stroke (or other types of strokes), myocardial infarction, and accelerations of preexisting breast tumors.
The home care nurse suspects that a client's spouse is experiencing caregiver strain. Which action should the nurse take to assess for this condition?
- A. Referring the family to a social services agency
- B. Gathering data from the caregiver and the client
- C. Waiting for the caregiver to talk about the stress
- D. Obtaining feedback from the client about the caregiver
Correct Answer: B
Rationale: Caregiver strain can occur when a client is significantly dependent on the caregiver for personal and health care needs. The nurse gathers data from the client and the caregiver to determine the caregiver's stressors and coping abilities and withholds making any referrals until the assessment is complete and the plan of care is in place. Because the nurse suspects caregiver strain, the nurse fulfills the duty to the client and family by approaching the family with the concern, gathering assessment data, and planning care. The nurse does not expect the client to assess the coping abilities of the caregiver because assessment is part of the nursing process and should not be delegated.
The nurse instructs a client who is hospitalized and on a low-fat diet. Which menu does the nurse provide for the client?
- A. Shrimp, avocado, and tomato salad
- B. Calf's liver, potato salad, and sherbet
- C. Lean steak, mashed potatoes, and gravy
- D. Turkey breast, boiled rice, and strawberries
Correct Answer: D
Rationale: Turkey breast without the skin, boiled rice, and strawberries offer the client nourishing foods that are low in fat. Some sources of fat include meats, avocado, salad dressing, mayonnaise, butter, cheese, and bacon. The remaining options contain high-fat foods.
The community health nurse provides an educational session regarding the risk factors for cervical cancer to women in the local community. The nurse determines that further teaching is needed if a woman attending the session identifies which as a risk factor for this type of cancer?
- A. Smoking tobacco
- B. Single sex partner
- C. Early age of first intercourse
- D. Human papillomavirus (HPV) infection
Correct Answer: B
Rationale: Having a single sex partner is not a risk factor for cervical cancer. Some risk factors for cervical cancer include having multiple sexual partners or a partner who had multiple sexual partners, smoking tobacco, early age of first intercourse, and HPV infection.