Nokea
The nurse is reinforcing teaching for a client who is prescribed acyclovir for genital herpes. Which statement should be included by the nurse?
- A. Adhesive bandaging should remain on the lesions to prevent virus shedding
- B. Blood tests will be drawn to ensure that the virus is eradicated
- C. Condoms should be used during intercourse until the lesions are healed
- D. Gloves should be used to apply the medication to the lesions
Correct Answer: D
Rationale: Acyclovir (Zovirax), famciclovir, and valacyclovir are commonly used to treat herpes infection as they shorte
the duration and severity of active lesions. Genital herpes is a sexually transmitted infection caused by a
herpes simplex virus and is highly contagious, especially when lesions are active. It remains dormant in the
body even when active lesions are healed; however, it is still contagious, even when dormant. The infection
can be spread to other people or other parts of the body via skin-to-skin contact; therefore, gloves should be
used when applying topical antiviral or analgesic (eg, lidocaine) medications. There is no cure for genital
herpes; treatment is aimed at relieving symptoms and preventing the spread of infection
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The nurse should recognize that physical dependence is accompanied by what findings when alcohol consumption is first reduced or ended?
- A. Seizures
- B. Withdrawal
- C. Craving
- D. Marked tolerance
Correct Answer: B
Rationale: Withdrawal. Early withdrawal symptoms, including nausea and tremor, appear within hours of reducing alcohol intake.
A client is brought to the emergency room following a motor vehicle accident. When assessing the client one-half hour after admission, the nurse notes several physical changes. Which finding would require the nurse's immediate attention?
- A. increased restlessness
- B. tachycardia
- C. tracheal deviation
- D. tachypnea
Correct Answer: C
Rationale: tracheal deviation. The deviated trachea is a sign that a mediastinal shift has occurred. This is a medical emergency.
Which situations require that the nurse report to an appropriate authority? Select all that apply.
- A. Client has a row of 3-inch circles down the back from 'cupping'
- B. Client is diagnosed with gonorrhea and requests not to report under the Health Insurance Portability and Accountability Act (HIPAA)
- C. RN thinks a teenage client’s signs are from abuse, but the health care provider does not
- D. RN thinks an elderly client’s signs are from abuse but the client denies this
- E. Syphilis is diagnosed in an 11-year-old who denies sexual activity
Correct Answer: B,C,D,E
Rationale: Gonorrhea (B) and syphilis (E) are reportable diseases, regardless of HIPAA. Suspected abuse in a teenager (C) or elderly client (D) mandates reporting, despite provider or client denial. Cupping (A) is a cultural practice, not abuse.
A 1-year-old boy is hospitalized for a fractured femur. There is a PRN order for pain medication. What is the best way to assess the child for pain?
- A. Ask the parent who is present if the child appears to be in pain.
- B. Observe the child's behavior carefully.
- C. Ask the child where it hurts and how badly it hurts.
- D. Have the child look at pictures of faces and select the one that best describes how he feels right now.
Correct Answer: B
Rationale: A 1-year-old cannot verbalize pain; observing behavior (e.g., crying, guarding) is the most reliable pain assessment method.
Which instruction should be given to a client taking Lugol's solution prior to a thyroidectomy?
- A. Take at bedtime.
- B. Take the medication with juice.
- C. Report changes in appetite.
- D. Avoid the sunshine while taking the medication.
Correct Answer: B
Rationale: Lugol's solution (iodine) should be taken with juice to mask its taste and reduce gastric irritation. Taking it at bedtime , reporting appetite changes , or avoiding sunshine are not specific to this medication.