Nokea
The patient is having difficulty coping with her new diagnosis of lymphoma. Which response by the nurse is most helpful?
- A. "Don't worry. You'll be okay."
- B. "The treatments you are receiving will make you feel better very soon."
- C. "Who do you usually go to when you have a problem?"
- D. "Have you made end-of-life decisions?"
Correct Answer: C
Rationale: Option C, "Who do you usually go to when you have a problem?" is the most helpful response by the nurse in this situation. This response allows the patient to identify her support system and opens up a conversation about coping mechanisms and sources of emotional support. It helps the nurse understand who the patient leans on during difficult times and enables the nurse to involve these individuals in providing support and encouragement to the patient as she copes with her new diagnosis of lymphoma. By exploring the patient's typical sources of support, the nurse can assist in strengthening her coping mechanisms and emotional well-being during this challenging time.
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Mr. Reyes is extremely confused. The nurse provide new information slowly and in small amounts because;
- A. Confusion or delirium can be a defense against further stress
- B. Destruction of brain cells has occurred, interrupting mental activity
- C. Teaching based on information progressing from the simple to the complex
- D. A minimum of information should be given, since he is unaware of surrounding
Correct Answer: A
Rationale: Providing new information slowly and in small amounts to a confused individual, like Mr. Reyes, is important because confusion or delirium can be a defense mechanism against further stress. By giving information gradually, it allows the individual to better absorb and process the information without becoming overwhelmed, which can further exacerbate their confusion. This approach also helps reduce the risk of causing additional stress or agitation in the individual, thus promoting a more conducive environment for cognitive processing and understanding.
The MOST common cause of sleeping difficulty in the first 2 months of life is
- A. gastro-esophageal reflux
- B. colic
- C. formula intolerance
- D. developmentally self-resolving sleeping behavior
Correct Answer: B
Rationale: Colic is a frequent cause of sleep difficulties in young infants.
Daya's child is scheduled for surgerydue to myelomeningocele; the primary reason for surgical repair is which of thefollowing?
- A. To prevent hydrocephalus
- B. To reduce the risk of infection
- C. To correct the neurologic defect
- D. To prevent seizure disorders
Correct Answer: C
Rationale: The primary reason for surgical repair of myelomeningocele is to correct the neurologic defect caused by this type of birth defect. Myelomeningocele is a form of spina bifida where the spinal cord and its covering are exposed through an opening in the spine. Surgical closure of the defect is performed to protect the spinal cord and nerves, prevent further damage, and potentially improve long-term outcomes for the child. While preventing complications like hydrocephalus or infection may be important secondary goals of the treatment, the main objective of surgery for myelomeningocele is to address the underlying neurologic defect itself.
The nurse evaluates a certified nursing assistant. Which of the following actions by the CAN demonstrates understanding of standard precautions?
- A. Wears gloves during all client contact
- B. Cleans blood spills with soap and water
- C. Pours bulk blood and other secretions down a drain connected to a sanitary sewer
- D. Carries blood sample to the lab in an open basket
Correct Answer: A
Rationale: The correct action that demonstrates understanding of standard precautions is wearing gloves during all client contact. Standard precautions are designed to prevent the transmission of infectious agents from both recognized and unrecognized sources of infection. Wearing gloves during client contact helps protect both the patient and the healthcare worker from potential infection transmission through contact with bodily fluids, skin, mucous membranes, and non-intact skin. Cleaning blood spills with soap and water is also part of standard precautions to prevent the spread of infection. However, pouring bulk blood and other secretions down a drain connected to a sanitary sewer and carrying a blood sample to the lab in an open basket do not align with standard precautions and could pose infection control risks.
A client with human immunodeficiency virus (HIV) undergoes intradermal anergy testing using Candida and mumps antigen. During the 3 days following the tests, there is no induration or evidence of reaction at the intradermal injection sites. The most accurate conclusion the nurse can make is:
- A. The client has no previous exposure to the antigens injected
- B. The results demonstrate the client has antibodies to the antigens
- C. The client is immunodeficient and won't have a skin response
- D. The client isn't allergic to the antigens and therefore doesn't react
Correct Answer: C
Rationale: A client with HIV undergoing intradermal anergy testing with Candida and mumps antigens is suspected to be immunodeficient, making them unable to mount a normal skin response to these antigens. In an immunodeficient individual, the immune system is weakened, leading to a lack of response when exposed to these antigens. A lack of induration or reaction in the 3 days following the test suggests that the client's immune system is not able to mount a normal response, indicating immunodeficiency. The absence of a reaction does not necessarily indicate lack of exposure (Option A), presence of antibodies (Option B), or the absence of allergies (Option D), but rather points to a compromised immune system in an individual with HIV.