Nokea
What is an appropriate intervention for the client with suspected genitourinary trauma and visible blood at the urethral meatus?
- A. Insertion of a Foley catheter.
- B. Performing an in-and-out catheter specimen for urinalysis.
- C. Obtaining a voided urine specimen for urinalysis.
- D. Ordering a urinalysis by the physician.
Correct Answer: D
Rationale: When a client presents with suspected genitourinary trauma and visible blood at the urethral meatus, obtaining a voided urine specimen for urinalysis is an appropriate intervention. This helps assess for any urinary tract injuries or abnormalities without further traumatizing the area. Insertion of a Foley catheter (Choice A) should be avoided as it can worsen the existing trauma. Performing an in-and-out catheter specimen (Choice B) involves unnecessary manipulation and can increase the risk of complications. Ordering a urinalysis by the physician (Choice D) may delay the assessment compared to obtaining a direct voided urine specimen.
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A nurse working in a pediatric clinic observes the following situations. Which of the following may indicate a delayed child to the nurse?
- A. A 12-month-old that does not 'cruise'.
- B. An 8-month-old that can sit upright unsupported.
- C. A 6-month-old that is rolling prone to supine.
- D. A 3-month-old that does not roll supine to prone.
Correct Answer: A
Rationale: The correct answer is 'A 12-month-old that does not 'cruise''. At 12 months, a child should at least be 'cruising' (holding on to objects to walk), which is considered pre-walking. The other choices describe age-appropriate developmental milestones: sitting upright unsupported by 8 months, rolling prone to supine by 6 months, and rolling supine to prone by 3 months. Not 'cruising' at 12 months may indicate a delay in motor skills development.
A violation of a patient's confidentiality occurs if two nurses are discussing client information in which of the following scenarios?
- A. With a physical therapist treating the patient
- B. With a social worker planning for discharge
- C. With another nurse on duty to plan for break time
- D. In the hallway outside the patient's room
Correct Answer: D
Rationale: The correct answer is 'In the hallway outside the patient's room.' Discussing client information in a public area like a hallway can potentially breach patient confidentiality as it increases the risk of unauthorized individuals overhearing sensitive information. Choices A, B, and C involve discussing client information with other healthcare professionals in appropriate settings, which are more likely to maintain patient confidentiality compared to discussing in a public space like a hallway. Option D is the correct choice because it highlights a scenario where patient information is at higher risk of exposure to unauthorized individuals, hence violating patient confidentiality.
Which of the following viruses is most likely to be acquired through casual contact with an infected individual?
- A. influenza virus
- B. herpes virus
- C. cytomegalovirus (CMV)
- D. human immunodeficiency virus (HIV)
Correct Answer: A
Rationale: The correct answer is influenza virus. Influenza virus is most likely to be acquired through casual contact with an infected individual as it is transmitted through respiratory droplets. Herpes virus is primarily transmitted by direct contact, such as skin-to-skin contact, making it less likely to be acquired through casual contact. HIV is mainly transmitted through blood and body fluids like semen and vaginal fluids, not through casual contact. Cytomegalovirus (CMV) is an opportunistic infection commonly affecting immunocompromised individuals and is usually transmitted through close personal contact, not casual contact.
What is the drug of choice for herpes simplex virus 1, herpes simplex virus 2, and varicella-zoster virus?
- A. HIV.
- B. HSV 1, HSV 2, and VZV.
- C. CMV
- D. Influenza A viruses.
Correct Answer: B
Rationale: Acyclovir (Zovirax) is the drug of choice for herpes simplex virus 1 (HSV-1), herpes simplex virus 2 (HSV-2), and varicella-zoster virus (VZV) infections. It works by inhibiting viral DNA replication. Acyclovir is excreted unchanged in the urine, so caution is needed in renal impairment. Choice A, HIV, is incorrect as acyclovir is not the drug of choice for HIV. Choice C, CMV, is incorrect as acyclovir is not the preferred treatment for cytomegalovirus (CMV) infections. Choice D, Influenza A viruses, is incorrect as acyclovir is not used to treat influenza viruses.
A 21-year-old college student has just learned that she contracted genital herpes from her sexual partner. After completing the initial history and assessment, the nurse has data concerning areas pertinent to the disease. The data is likely to include all but which of the following?
- A. voiding patterns
- B. characteristics of lesions
- C. vaginal discharge
- D. prior history of varicella
Correct Answer: D
Rationale: The correct answer is 'prior history of varicella.' When assessing a client with genital herpes, it is important to gather data on voiding patterns, characteristics of lesions, and vaginal discharge as these are pertinent to the disease. However, the prior history of varicella is not directly related to the current diagnosis of genital herpes. Varicella, which refers to chickenpox, is caused by the varicella-zoster virus, a different virus from the herpes simplex virus causing genital herpes.