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Which of the ff nursing interventions ensure that a client with Hodgkin's disease remains free of infection? Choose all that apply
- A. Apply ice to the skin for brief periods
- B. Provide cool sponge baths
- C. Practice conscientious hand washing
- D. Use cotton gloves Restrict visitors or personnel with infections from contact with the client
Correct Answer: C
Rationale: #NAME?
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A 5-year old boy presents with afebrile generalized tonic-clonic seizure lasting for 5 minutes. Previously he was healthy and had no such problem. On examination there is no abnormality. Your plan of management should be:
- A. Start anticonvulsant therapy
- B. Request for an EEG and wait for its report
- C. Request for an EEG and start anticonvulsant therapy immediately
- D. Request for EEG and MRI brain
Correct Answer: C
Rationale: In a first-time generalized seizure, an immediate EEG and starting anticonvulsant therapy is prudent to prevent recurrence, especially if the EEG shows epileptiform activity.
A client with autoimmune thrombocytopenia and a platelet count of 8,000/ul develops epistaxis and melena. Treatment with corticosteroids and immunoglobulins has been unsuccessful, and the physician recommends a splenectomy. The client states, "I don't need surgery-this will go away on its own". In considering her response to the client, the nurse must depend on the ethical principle of:
- A. Beneficence
- B. Advocacy
- C. Autonomy
- D. Justice
Correct Answer: C
Rationale: The ethical principle most relevant in this situation is autonomy. Autonomy refers to a person's right to make decisions about their own care and treatment. In this case, the client is expressing her wish to avoid surgery and believes her condition will improve on its own. It is important for the nurse to respect the client's autonomy and involve her in the decision-making process regarding her treatment. The nurse should provide information, support, and guidance to help the client make an informed decision that aligns with her values and preferences. While the nurse can provide education and encourage the client to consider the physician's recommendation, ultimately the decision should respect the client's autonomy.
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 nurse is caring for four patients; three are toddlers and one is a preschooler. Which represents the major stressor of hospitalization for these four patients?
- A. Separation anxiety
- B. Loss of control
- C. Fear of bodily injury
- D. Fear of pain
Correct Answer: A
Rationale: Separation anxiety is the major stressor of hospitalization for these young patients. Toddlers and preschoolers are at a critical stage of development where they are developing close attachments to their primary caregivers. Being separated from their parents or primary caregivers when admitted to the hospital can lead to feelings of fear, distress, and insecurity. This separation can significantly impact their emotional well-being and overall hospital experience. Loss of control, fear of bodily injury, and fear of pain are also stressors associated with hospitalization, but separation anxiety is the primary concern for these young patients due to their developmental stage.
The nurse is conducting teaching for an adolescent being discharged to home after a renal transplant. The adolescent needs further teaching if which statement is made?
- A. "I will report any fever to my primary health care provider."
- B. "I am glad I only have to take the immunosuppressant medication for two weeks."
- C. "I will observe my incision for any redness or swelling."
- D. "I won't miss doing kidney dialysis every week."
Correct Answer: B
Rationale: The statement "I am glad I only have to take the immunosuppressant medication for two weeks" indicates a misunderstanding about the long-term nature of immunosuppressant therapy following a renal transplant. In reality, individuals who undergo a renal transplant need to take immunosuppressant medications for the rest of their lives to prevent rejection of the donor kidney. Failure to adhere to this medication regimen can result in rejection of the transplanted kidney. Therefore, this statement indicates a need for further teaching to ensure the adolescent understands the importance of lifelong immunosuppressant therapy.