Nokea
The nurse is taking a sexual history on an adolescent girl. Which is the best way to determine whether she is sexually active?
- A. Ask her, "Are you sexually active?"
- B. Ask her, "Are you having sex with anyone?"
- C. Ask her, "Are you having sex with a boyfriend?"
- D. Ask both the girl and her parent whether she is sexually active.
Correct Answer: A
Rationale: The best way to determine whether an adolescent girl is sexually active is to ask her directly, "Are you sexually active?" This question is concise, clear, and non-judgmental, allowing the girl to provide a straightforward answer. It is important to create a safe and open environment for discussing sexual health, and using direct language helps ensure accurate communication. Asking about specific partners (options B and C) may lead to confusion or misinterpretation, and involving the parent (option D) without the girl's consent may violate her privacy and autonomy. Therefore, direct communication with the adolescent herself is the most appropriate approach to gather information about her sexual activity.
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Will is being assessed by Nurse Lucas for possible intussusception; which of the following would be least likely to provide valuable information?
- A. Abdominal palpation
- B. Family history
- C. Pain pattern
- D. Stool inspection
Correct Answer: B
Rationale: When assessing a patient like Will for possible intussusception, the least likely to provide valuable information would be the family history. While family history can help identify potential genetic predispositions or conditions that may contribute to a patient's current health concerns, in this case, the focus is on Will's immediate symptoms and diagnostic indicators related to possible intussusception. Abdominal palpation, pain pattern assessment, and stool inspection are more directly relevant to evaluating Will's current condition and determining the likelihood of intussusception. Family history, while important in a broader health context, would be least likely to provide immediate insights into Will's specific situation with intussusception.
What is the rationale for giving Mr. Franco frequent mouth care?
- A. He will be thirsty considering that he is doesn't drink enough fluids
- B. To remove dried blood when tongue is bitten during a seizure
- C. The tactile stimulation during mouth care will hasten return to consciousness
- D. Mouth breathing is used by comatose patient and it'll cause oral mucosa dying and cracking.
Correct Answer: B
Rationale: Giving Mr. Franco frequent mouth care is important to remove dried blood when the tongue is bitten during a seizure. Seizures can cause involuntary biting of the tongue, leading to the accumulation of dried blood in the mouth. If this blood is not removed promptly, it can result in discomfort, infection, and potential complications. Regular oral care helps maintain oral hygiene and prevents any issues related to oral trauma during seizures, promoting overall health and well-being for the patient.
Veronica's parents were told that their daughter needs ribavirin (Virazole). This drug is used to treat which of the following?
- A. Cystic fibrosis
- B. Otitis media
- C. Respiratory syncytial virus (RSV)
- D. Bronchitis
Correct Answer: C
Rationale: Ribavirin (Virazole) is an antiviral medication used to treat severe cases of respiratory syncytial virus (RSV) infection in infants, young children, and immunocompromised individuals. RSV is a common virus that causes respiratory infections in people of all ages, but it can be particularly severe in young children and individuals with weakened immune systems. Ribavirin works by preventing the virus from replicating and spreading further in the body, helping to reduce the severity and duration of RSV infection. It is not used to treat cystic fibrosis, otitis media, or bronchitis.
The nurse in the postoperative unit prepares to receive a client after a balloon angioplasty of the carotid artery. Which of the ff items of priority should the nurse keep at the bedside for such client?
- A. Blood pressure apparatus
- B. IV infusion stand
- C. Call bell
- D. Endotracheal intubation
Correct Answer: A
Rationale: Having a blood pressure apparatus at the bedside is a priority for a client following a balloon angioplasty of the carotid artery. Monitoring blood pressure closely is essential to assess for any signs of complications such as bleeding or thrombosis after the procedure. Rapid identification and management of any changes in blood pressure are crucial in the immediate postoperative period to ensure the client's safety and well-being. It allows the nurse to promptly intervene if there are any signs of complications, helping to prevent further harm to the client.
Which of the following blood types would the nurse identify as the rarest?
- A. A
- B. AB
- C. B
- D. O
Correct Answer: B
Rationale: Blood type AB is the rarest of all the blood types. This is because individuals with AB blood type have both A and B antigens on their red blood cells, making it less common than other blood types. In the ABO blood group system, the distribution of blood types in the general population is approximately 45% type O, 40% type A, 11% type B, and only about 4% type AB. Therefore, blood type AB would be identified as the rarest in the given options.