Nokea
The nurse is teaching a patient preventative measures regarding vaginal infections. The nurse should include which of the following as an important risk factor?
- A. High estrogen levels
- B. Late menarche
- C. Nonpregnant state
- D. Frequent douching
Correct Answer: D
Rationale: The correct answer is D: Frequent douching. Douching disrupts the natural balance of vaginal flora, making the environment more susceptible to infections. High estrogen levels (A) can actually protect against vaginal infections. Late menarche (B) and nonpregnant state (C) are not direct risk factors for vaginal infections. In summary, frequent douching is the most significant risk factor as it disrupts the vaginal microbiome.
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The nurse is concerned about pulmonary aspiration when providing the patient with an intermittent tube feeding. Which action is thepriority?
- A. Observe the color of gastric contents.
- B. Verify tube placement before feeding.
- C. Add blue food coloring to the enteral formula.
- D. Run the formula over 12 hours to decrease overload.
Correct Answer: B
Rationale: The correct answer is B because verifying tube placement before feeding is essential to prevent pulmonary aspiration. If the tube is not correctly positioned in the stomach, there is a risk of feeding going into the lungs. Observing the color of gastric contents (A) may not always indicate correct placement. Adding blue food coloring (C) is unnecessary and could cause confusion. Running the formula over 12 hours (D) does not address the risk of pulmonary aspiration and does not ensure proper tube placement.
Which behaviors indicate the student nurse hasa good understanding of confidentiality and the Health Insurance Portability and Accountability Act (HIPAA)? (Selectall that apply.)
- A. Writes the patient’s room number and date of birth on a paper for school
- B. Prints/copies material from the patient’s health record for a graded care plan
- C. Reviews assigned patient’s record and another unassigned patient’s record
- D. Gives a change-of-shift report to the oncoming nurse about the patient
Correct Answer: D
Rationale: Correct Answer: D
Rationale:
- Giving a change-of-shift report to the oncoming nurse about the patient is an appropriate action that maintains confidentiality by only sharing necessary patient information with authorized healthcare professionals.
- A: Writing the patient’s room number and date of birth on a paper for school is a breach of confidentiality as it exposes sensitive patient information to unauthorized individuals.
- B: Printing/copying material from the patient’s health record for a graded care plan is also a breach of confidentiality as it involves sharing patient information without proper authorization.
- C: Reviewing assigned patient’s record and another unassigned patient’s record is a violation of HIPAA as it involves accessing patient information that is not necessary for the nurse's duties, risking unauthorized disclosure.
In determining malnourishment in a patient, which assessment finding is consistent with this disorder?
- A. Moist lips
- B. Pink conjunctivae
- C. Spoon-shaped nails
- D. Not easily plucked hair
Correct Answer: C
Rationale: Step 1: Malnourishment often leads to iron deficiency anemia, causing spoon-shaped nails (koilonychia).
Step 2: Koilonychia is a classic sign of chronic malnutrition and iron deficiency.
Step 3: Moist lips (A) and pink conjunctivae (B) are not specific to malnourishment.
Step 4: Not easily plucked hair (D) is more related to hair health rather than malnutrition.
A 14-year-old is brought to the clinic by her mother. The mother explains to the nurse that her daughter has just started using tampons, but is not yet sexually active. The mother states I am very concerned because my daughter is having a lot of stabbing pain and burning. What might the nurse suspect is theproblem with the 14-year-old?
- A. Vulvitis
- B. Vulvodynia
- C. Vaginitis
- D. Bartholins cyst
Correct Answer: B
Rationale: The correct answer is B: Vulvodynia. Vulvodynia is characterized by chronic vulvar pain or discomfort, including stabbing pain and burning, without an identifiable cause. In this case, the young girl is experiencing these symptoms despite not being sexually active, ruling out other conditions like vulvitis (inflammation of the vulva), vaginitis (inflammation of the vagina), and Bartholin's cyst (fluid-filled swelling near the vaginal opening). The absence of sexual activity suggests that the pain is not related to an infection or trauma, further supporting the diagnosis of vulvodynia.
A nurse is sitting at the patient’s bedside takinga nursing history. Which zone of personal space is the nurse using?
- A. Socio-consultative
- B. Personal
- C. Intimate
- D. Public
Correct Answer: B
Rationale: The nurse sitting at the patient's bedside is using the personal zone of personal space, which ranges from 18 inches to 4 feet. This distance allows for a close interaction suitable for taking a nursing history while maintaining a professional yet personal connection. The socio-consultative zone (A) is 4-12 feet, more appropriate for professional interactions. The intimate zone (C) is 0-18 inches, too close for an initial nursing history. The public zone (D) is 12 feet or more, too distant for a personal conversation.