Nokea
The nurse is teaching a 17-year-old girl who has a severe gonorrheal infection. The nurse realizes that the girl needs further teaching when she states:
- A. Once I'm treated, I'll have immunity.'
- B. My partner doesn't need treatment.'
- C. I won't have any more problems once I learn to protect myself.'
- D. I could have trouble getting pregnant.'
Correct Answer: A,B
Rationale: Gonorrhea does not confer immunity, and partners require treatment to prevent reinfection. Potential infertility is a correct understanding, but believing protection eliminates all problems is overly optimistic.
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The nurse is teaching a client with a new diagnosis of hypertension about medication adherence. Which of the following statements by the client indicates a need for further teaching?
- A. I'll take my medication every morning.'
- B. I'll check my blood pressure regularly.'
- C. I'll stop my medication if I feel fine.'
- D. I'll avoid high-sodium foods.'
Correct Answer: C
Rationale: Stopping medication when feeling fine indicates a misunderstanding, as hypertension requires ongoing treatment.
The nurse is assessing a newborn 24 hours after birth. Which finding requires immediate reporting?
- A. Milia on the nose
- B. Mongolian spots on the back
- C. Caput succedaneum
- D. Yellowing of the skin
Correct Answer: D
Rationale: Yellowing of the skin within 24 hours suggests pathological jaundice, requiring immediate evaluation to prevent complications like kernicterus.
You are caring for a group of elderly clients, many of whom are affected with multiple chronic disorders and are also, at times, affected with some acute disorders that require medical and nursing attention. As you are caring for these clients some will need a new medication regimen for an acute disorder. You should consider that fact that the elderly population is at risk for more side effects, adverse drug reactions, and toxicity and over dosages of medications because the elderly have a (n):
- A. Increased creatinine clearance.
- B. Impaired immune system.
- C. Decreased hepatic metabolism.
- D. Increased bodily fat.
Correct Answer: C
Rationale: Elderly individuals often have decreased hepatic metabolism due to reduced liver function, which affects drug metabolism and increases the risk of side effects, adverse reactions, and toxicity.
Your client has superior vena cava syndrome. The client's wife asks you what this is. How should you respond to the client's wife? You should explain that superior vena cava syndrome is:
- A. The compression of the renal medulla.
- B. Syncope and dizziness of unknown origin.
- C. Pressure on the vena cava which is a major vein in the body.
- D. Pressure on the vena cava which is the largest artery in the body.
Correct Answer: C
Rationale: Superior vena cava syndrome is caused by compression of the superior vena cava, a major vein, leading to symptoms like swelling and shortness of breath.
The nurse is caring for a client with a chest tube in place for a pneumothorax. Which of the following findings indicates that the chest tube is functioning properly?
- A. Continuous bubbling in the water seal chamber.
- B. Absence of tidaling in the water seal chamber.
- C. Fluctuation of fluid in the drainage tube with respiration.
- D. No drainage in the collection chamber.
Correct Answer: C
Rationale: Fluctuation (tidaling) in the drainage tube with respiration indicates the chest tube is patent and functioning to remove air or fluid.