Nokea
The nurse is preparing to read the Mantoux tuberculin skin test placed on the forearm of a patient with HIV. Which finding should the nurse report as a positive test for this patient?
- A. 2 mm
- B. 3 mm
- C. 4 mm
- D. 5 mm
Correct Answer: D
Rationale: The correct answer is D (5 mm) for a positive Mantoux test in a patient with HIV. In HIV-positive individuals, a positive test is considered when the induration is ≥5 mm. This is because the immune system may be compromised, leading to a delayed immune response. Choices A, B, and C (2 mm, 3 mm, 4 mm) are not considered positive for HIV-positive individuals due to their weakened immune system, requiring a larger induration size to indicate a positive test.
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You are a home health nurse caring for an elderly client in their home. They have children and grandchildren but they live far from the couple and they typically visit with your clients once to two times a year. The elderly man is beginning to show some of the signs of Alzheimer's disease dementia. The wife is also 88 years of age and has had a stroke which has left her with left sided weakness, but she is willing to help her husband and to maintain his safety. What kind of support should you give the wife in terms of her role caring for her husband?
- A. You should advise the couple to move closer to their children so that they can care for their father.
- B. You should teach the wife about this progressive disease and the need to promote as much independence as possible.
- C. You should teach the wife about this progressive disease and the need to do all that she can for the husband to avoid his depression and frustration.
- D. You should advise the couple to decrease their social activities in order to preserve the husband's dignity and self-esteem.
Correct Answer: B
Rationale: Education on progression and independence (B) supports the wife's caregiving role.
Which experiencing actually increases our chances of success:
- A. Attitude
- B. Style
- C. Personality
- D. Positive emotions
Correct Answer: D
Rationale: Positive emotions (Fredrickson's broaden-and-build) enhance success by expanding resources.
The nurse psychotherapist is working with the Jones family in the outpatient mental health clinic. The husband says, 'We can’t agree on anything! And it seems like every time we disagree on something it ends up in a screaming match.' Which of the following prescriptions by the nurse represents a paradoxical intervention for the Jones family?
- A. Mr. and Mrs. Jones must not have a disagreement for one full day.
- B. Mr. and Mrs. Jones will yell at each other on Tuesdays and Thursdays from 8 p.m. until 8:10 p.m.
- C. Mr. and Mrs. Jones must refrain from yelling at each other until the next counseling session.
- D. Mr. and Mrs. Jones must not discuss serious issues until they can do so without yelling at each other.
Correct Answer: B
Rationale: The correct answer is B because a paradoxical intervention involves prescribing the symptom or issue that the client is struggling with. In this case, the Jones family is experiencing frequent yelling matches when they disagree. By prescribing a specific time for them to yell at each other, the nurse is challenging the dysfunctional pattern and creating an opportunity for them to confront and potentially change their behavior.
Choice A is incorrect because it simply avoids the issue without addressing the underlying problem. Choice C is incorrect as it also avoids the issue by postponing the yelling until the counseling session. Choice D is incorrect because it suggests avoiding serious discussions altogether, which doesn't address the root cause of the conflict.
A survivor of physical spousal abuse was treated in the emergency department for a broken wrist. This patient said, Ive considered leaving, but I made a vow and I must keep it no matter what happens. Which outcome should be met before discharge? The patient will:
- A. facilitate counseling for the abuser.
- B. name two community resources for help.
- C. demonstrate insight into the abusive relationship.
- D. reexamine cultural beliefs about marital commitment.
Correct Answer: B
Rationale: The only outcome indicator clearly attainable within this time is for staff to provide the victim with information about community resources that can be contacted. Development of insight into the abusive relationship and reexamining cultural beliefs will require time. Securing a restraining order can be accomplished quickly but not while the patient is in the emergency department. Facilitating the abusers counseling may require weeks or months.
The client's chart indicates that she has experienced trauma to the cerebral cortex as a result of injuries sustained during an attempted suicide. Which observation is most likely the result of this injury?
- A. Client is often found crying into her pillow.
- B. Client demonstrates involuntary twitching of facial muscles.
- C. Client states, 'What do you mean 'it's raining cats and dogs'?'
- D. Client asks, 'Can you address this letter to my mom; I forget her address?'
Correct Answer: C
Rationale: The correct answer is C because trauma to the cerebral cortex can lead to difficulties understanding and interpreting language, resulting in the client's statement of confusion about the idiom "raining cats and dogs." This type of injury can affect the client's language comprehension and expression.
Choice A is incorrect because crying into a pillow is not directly related to trauma in the cerebral cortex. Choice B is incorrect as involuntary twitching of facial muscles is more indicative of motor-related issues, not language comprehension problems. Choice D is also incorrect as forgetting an address is more related to memory issues rather than language comprehension problems resulting from cerebral cortex trauma.