Nokea
The nurse teaches a client with genital herpes about effective comfort measures. Which statement by the client indicates a need for further teaching by the nurse?
- A. Sitz baths three times a day may help ease the pain.
- B. I can use anesthetic sprays or ointments for relief.
- C. Wearing loose clothing can reduce irritation.
- D. I really should try to limit irritation due to the pain.
Correct Answer: D
Rationale: The statement about limiting irritation due to pain is vague and suggests a misunderstanding of specific comfort measures. Sitz baths, anesthetic sprays, and loose clothing are appropriate measures to reduce discomfort and irritation from genital herpes lesions.
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A woman is admitted to the hospital for antibiotic therapy for pelvic inflammatory disease. She is in pain, with a rating of 7 on a scale of 0 to 10. What comfort measure can the nurse delegate to the unlicensed assistive personnel (UAP)?
- A. Administer Tylenol immediately
- B. Apply a heating pad to the lower abdomen.
- C. Position the client in a semi-Fowler's position.
- D. Teach the client to increase intake of fluids.
Correct Answer: C
Rationale: Positioning the client in a semi-Fowler's position can be delegated to a UAP to help alleviate discomfort. Administering medication, applying a heating pad, and teaching are tasks reserved for the nurse, as they require clinical judgment or specialized training.
A client with pelvic inflammatory disease is seen by the nurse 72 hours after starting oral antibiotics. Which finding leads the nurse to take immediate action?
- A. Feelings of anger that her partner infected her
- B. Loss stood over the line 2 days
- C. Auroxia and nausea
- D. Chills and a temperature of 101 F
Correct Answer: D
Rationale: Chills and a fever of 101°F suggest a persistent infection, requiring immediate adjustment of antibiotic therapy. Anger is a normal emotional response, and gastrointestinal symptoms like anorexia and nausea are common antibiotic side effects, but they do not warrant urgent action compared to signs of ongoing infection.
Before marriage, a female client has a blood test drawn for syphilis. The test reveals a positive Venereal infection. What information should the nurse give the client?
- A. Check with your future husband about last sexual activity.
- B. You must determine if you are pregnant at this time.
- C. Submit to a more specific treppmental test to confirm the infection.
- D. Agree to a benzathline penicillin G injection in multiple doses.
Correct Answer: C
Rationale: A positive syphilis screening test may be a false positive due to conditions like hepatitis or lupus. A more specific treponemal test, such as the fluorescent treponemal antibody absorption test, is needed to confirm the diagnosis before treatment. Checking sexual activity or pregnancy status is secondary, and multiple doses of penicillin are not standard for early syphilis.
A 26-year-old client with multiple sexual partners is being assessed for symptoms of dysuria and vaginal discharge. Because the results from the culture of the cervical cells are not available, the client will be treated for both Chlamydia and gonorrhea. Which question by the nurse is best?
- A. Do you have a history of sexually transmitted disease?
- B. When was your last sexual encounter?
- C. What did your symptoms begin?
- D. What are the names of your recent sexual partners?
Correct Answer: D
Rationale: Identifying and treating sexual partners is critical to prevent the spread of Chlamydia and gonorrhea. While history, timing of last encounter, and symptom onset are useful, contacting and treating partners is the priority to break the chain of transmission.
A nurse is assessing a client who presents with a scale in rash over the palms and soles of the feet and the feel, a client is assessing a client who presents with a scale in syphilis. Which statement of the nurse is appropriate?
- A. Reasure the client that this stage is not infectious unless she is pregnant.
- B. Assess the client that he is not being generalized weakness.
- C. Data gives and further assess the clients, lesions.
- D. Take a history regarding any cardiovascular symptoms.
Correct Answer: C
Rationale: The client's symptoms suggest secondary syphilis, characterized by a rash on the palms and soles due to spirochetes in the bloodstream. Further assessment of lesions is critical to confirm the diagnosis and guide treatment. Reassuring about non-infectiousness is incorrect, as secondary syphilis is highly infectious, and cardiovascular symptoms are more relevant in tertiary syphilis.