Nokea
The nurse tells a rape victim that even if she was protected against pregnancy by a contraceptive and the attention of taking any legal action against her assailant, she should still be checked by a physician for early detection of which of the following?
- A. Sexually transmitted disease.
- B. Anxiety reaction.
- C. Periurethral tears.
- D. Menstrual difficulties.
Correct Answer: A
Rationale: A physician should check for sexually transmitted diseases, as rape increases the risk of infection, which requires early detection and treatment.
You may also like to solve these questions
The nurse working in the mental health unit is collecting data on a newly admitted client. Which data is a primary type of subjective data collection?
- A. Client complains of a headache.
- B. Client's blood pressure is 145/88.
- C. Family member states that the client got into a fight.
- D. Police officer reports that a disturbance was created by the client.
Correct Answer: A
Rationale: Assessments are conducted by many professionals, including nurses, psychiatrists, social workers, dietitians, and other therapists. Subjective data include information that can be described or verified only by the client or family. The primary source of data is the client. Objective data can be observed or measured. Secondary sources of data may need to be collected if the client is experiencing psychosis, muteness, or catatonia. These sources of data include family, friends, neighbors, police officers, health care workers, and medical records.
The nurse is caring for a client at risk for suicide. Which client behavior best indicates that the client may be contemplating suicide?
- A. Sharing that she or he is finally happy
- B. Sitting and crying for long periods of time
- C. Preferring to spend long periods of time alone
- D. Reporting a variety of sleep pattern disturbances
Correct Answer: A
Rationale: If a client displays a suicidal ideation and is able to share a plan, it should be taken very seriously and suicide precautions should be implemented. Expressing happiness shows a contentment that is often a sign that a suicide plan has been created. The remaining options are indicative of depression but are not as definitive in regard to suicide.
A client with a diagnosis of polycythemia vera is prescribed hydroxyurea (Hydrea). The nurse should monitor the client for which of the following side effects?
- A. Hypertension.
- B. Bone marrow suppression.
- C. Hyperkalemia.
- D. Weight gain.
Correct Answer: B
Rationale: Hydroxyurea can cause bone marrow suppression, requiring monitoring of blood counts for anemia or leukopenia.
The nurse is caring for a client with a history of burns. Which of the following interventions should be included in the plan of care? Select all that apply.
- A. Monitor urine output.
- B. Administer tetanus prophylaxis.
- C. Provide psychological support.
- D. Restrict visitors to prevent infection.
- E. Apply cold compresses to burns.
Correct Answer: A, B, C
Rationale: Monitoring urine output, tetanus prophylaxis, and psychological support are essential. Visitors should be screened, not restricted, and cold compresses are contraindicated.
The nurse observes an 18-month-old who has been admitted with a respiratory tract infection (see figure). The nurse should first:
- A. Position the child supine
- B. Call the rapid response team
- C. Offer the child a carbonated drink
- D. Place the child in a croup tent
Correct Answer: B
Rationale: An 18-month-old with a respiratory tract infection may be in respiratory distress, requiring immediate action by calling the rapid response team. Positioning supine or offering a drink could worsen breathing, and a croup tent is specific to croup, not all infections.