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The nurse is caring for a client who is HIV positive. To prevent the spread of the HIV virus, what do the Centers for Disease Control and Prevention recommend?
- A. Universal blood and body fluid precautions
- B. Body systems isolation
- C. Laminar flow room during active infection
- D. Needle and syringe precautions
Correct Answer: A
Rationale: The Centers for Disease Control and Prevention (CDC) recommend universal blood and body fluid precautions for preventing the spread of the HIV virus. These precautions are designed to protect healthcare workers and patients from exposure to bloodborne pathogens. Universal precautions involve treating all blood and body fluids from all individuals as potentially infectious. This includes using personal protective equipment (such as gloves, gowns, and masks), proper handling and disposal of needles and other sharps, and following appropriate infection control practices. By implementing universal precautions, healthcare providers can minimize the risk of transmission of HIV and other bloodborne pathogens.
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The nurse is caring for an adolescent who has just started dialysis. The child seems always angry, hostile, or depressed. To what are these behaviors most likely related?
- A. Neurologic manifestations that occur with dialysis
- B. Physiologic manifestations of renal disease
- C. Adolescents having few coping mechanisms
- D. Adolescents often resenting the control and enforced dependence imposed by dialysis
Correct Answer: D
Rationale: Adolescents often resent the control and enforced dependence imposed by dialysis. Adolescence is a challenging time marked by striving for independence and autonomy. When adolescents have to rely on medical interventions like dialysis that impose control and dependence, it can lead to feelings of anger, hostility, and depression. This is a normal psychological response to feeling restricted and not in control of their own lives. It is important for healthcare providers to recognize these emotions and provide support and coping strategies to help the adolescent adjust to the situation.
Which of the ff. nursing actions is most appropriate when doing perineal care on an uncircumcised male patient?
- A. Leave the foreskin retracted so air can keep the area dry
- B. Do not retract the foreskin during washing
- C. Replace the foreskin over the head of the penis after washing
- D. Use alcohol and a cotton swab to clean under the foreskin
Correct Answer: C
Rationale: When performing perineal care on an uncircumcised male patient, it is important to replace the foreskin over the head of the penis after washing. The foreskin should not be left retracted or pulled back forcibly as it can cause irritation and discomfort to the patient. Leaving the foreskin retracted can also lead to potential complications such as paraphimosis, where the foreskin becomes trapped behind the head of the penis. Proper hygiene involves gently retracting the foreskin to clean underneath it and then returning it to its natural position to protect the sensitive glans penis. Using gentle, warm water with mild soap is typically sufficient for cleaning, and alcohol should be avoided as it can cause irritation and dryness to the sensitive genital area.
The nurse should expect to assess which causative agent in a child with warts?
- A. Bacteria
- B. Fungus
- C. Parasite
- D. Virus
Correct Answer: D
Rationale: Warts are typically caused by a viral infection, specifically the human papillomavirus (HPV). This virus infects the top layer of the skin, causing the skin cells to grow rapidly, leading to the formation of a wart. Other causative agents such as bacteria, fungus, and parasites do not typically cause warts in children. Therefore, when assessing a child with warts, the nurse should expect the causative agent to be a virus, specifically HPV.
The age of a child who imitates construction of a bridge of 3 cubes; copies circle; makes tower of 10 cubes is
- A. 24 months old
- B. 30 months old
- C. 36 months old
- D. 42 months old
Correct Answer: C
Rationale: These milestones are typically achieved around 36 months.
The nurse is caring for an adolescent brought to the hospital with acute drug toxicity. Cocaine is believed to be the drug involved. Data collection should include what information?
- A. Mode of administration
- B. Drug's actual content
- C. Function the drug plays in the adolescent's life
- D. Adolescent's level of interest in rehabilitation
Correct Answer: A
Rationale: When caring for an adolescent with acute drug toxicity, it is important to gather information on the mode of administration of the drug to understand how it was taken into the body. This information can help the healthcare team determine the extent of drug exposure, potential complications, and appropriate treatment strategies. The mode of administration can include ingestion, inhalation, injection, or other routes, and each method may have different implications for the patient's condition. Understanding how the drug was administered is crucial in managing the adolescent's care effectively.