Nokea
Which interventions should the nurse discuss with the female client who is positive for human immunodeficiency virus (HIV)? Select all that apply.
- A. Recommend the client not to engage in unprotected sexual activity.
- B. Instruct the client not to inform past sexual partners of HIV status.
- C. Tell the client to not donate blood, organs, or tissues.
- D. Suggest the client not get pregnant.
- E. Explain the client does not have to tell health-care personnel of HIV status.
Correct Answer: A,C,D
Rationale: Unprotected sex, blood/organ donation, and pregnancy risk HIV transmission or complications. Partner notification and informing healthcare personnel are recommended.
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The client diagnosed with Guillain-Barré syndrome is on a ventilator. When the wife comes to visit, she starts crying uncontrollably, and the client starts fighting the ventilator because his wife is upset. Which action should the nurse implement?
- A. Tell the wife she must stop crying.
- B. Escort the wife out of the room.
- C. Medicate the client immediately.
- D. Acknowledge the wife's fears.
Correct Answer: D
Rationale: Acknowledging the wife’s fears provides emotional support, potentially calming both her and the client. Ordering her to stop, escorting her out, or medicating the client are less therapeutic.
The female client is homeless and pregnant. The client supports an IV drug habit by prostitution. Which data would be considered antecedents (risk factor) for becoming HIV positive? Select all that apply.
- A. The client is pregnant.
- B. The client is an intravenous drug abuser.
- C. The client has multiple sexual partners.
- D. The client does not have available health care.
- E. The client does not have adequate bathroom facilities.
- F. The client spends her money on nonessential items.
Correct Answer: B,C,D
Rationale: IV drug use, multiple sexual partners, and lack of healthcare increase HIV risk. Pregnancy, bathroom facilities, and spending are not direct risk factors.
The nurse in the holding area of the operating room is assessing the client prior to surgery. Which information warrants immediate intervention by the nurse?
- A. The client is able to mark the correct site for the surgery.
- B. The client can only tell the nurse about the surgery in lay terms.
- C. The client is allergic to iodine and does not have an allergy bracelet.
- D. The client has signed a consent form for surgery and anesthesia.
Correct Answer: C
Rationale: Missing an allergy bracelet for iodine risks exposure during surgery, requiring immediate intervention. Site marking, lay terms, and consent are appropriate.
The 30-year-old female client is admitted with complaints of numbness, tingling, a crawling sensation affecting the extremities, and double vision which has occurred two (2) times in the month. Which question is most important for the nurse to ask the client?
- A. Have you experienced any difficulty with your menstrual cycle?
- B. Have you noticed a rash across the bridge of your nose?
- C. Do you get tired easily and sometimes have problems swallowing?
- D. Are you taking birth control pills to prevent conception?
Correct Answer: C
Rationale: Fatigue and dysphagia are MS symptoms, and their presence supports the diagnosis. Menstrual issues, rashes (SLE-related), and birth control are less relevant to MS.
The nurse is assessing a client with cutaneous lupus erythematosus. Which intervention should be implemented?
- A. Use astringent lotion on the face and skin.
- B. Inspect the skin weekly for open areas or rashes.
- C. Dry the skin thoroughly by patting.
- D. Apply anti-itch medication between the toes.
Correct Answer: C
Rationale: Patting the skin dry prevents irritation in cutaneous lupus. Astringents worsen dryness, weekly inspections are too infrequent, and toe medication is irrelevant.