Nokea
A female client is diagnosed with human papillomavirus (HPV).
Which of the following client statements, if made to the nurse, illustrates an understanding of the possible sequelae of this illness?
- A. I will need to take antibiotics for at least a week.'
- B. I will use only prescribed douches to avoid a recurrence.'
- C. I will return for a Pap smear in six months.'
- D. I will avoid using tampons for eight weeks.'
Correct Answer: C
Rationale: Strategy: Determine the 'hidden meaning' of the answer choices. (1) antibiotics are not used for viral infections (2) douches will not prevent recurrence (3) correct-several strains of the human papillomavirus (HPV) are associated with cervical cancer (4) tampons would not be a problem as in toxic shock syndrome
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The nurse’s INITIAL priority when managing a physically assaultive client is to
- A. What is the initial priority when managing a physically assaultive client?
- B. Restrict the client to the room.
- C. Place the client under one-to-one supervision.
- D. Restore the client’s self-control and prevent further loss of control.
- E. Clear the immediate area of other clients to prevent harm.
Correct Answer: C
Rationale: Restoring the client’s self-control is the initial priority to ensure safety and prevent escalation. This involves assessing the situation, using psychological or chemical interventions, and possibly physical control. Room restriction, supervision, or clearing the area are secondary or impractical during rapid escalation.
A 9-year-old is admitted with suspected rheumatic fever. Which finding is suggestive of Syndeham's chorea?
- A. Irregular movements of the arms and legs and facial grimacing
- B. Painless swellings over the surface of the joints
- C. Faint areas of red demarcation over the back
- D. Swelling and inflammation of the joints
Correct Answer: A
Rationale: Syndeham's chorea is characterized by irregular, involuntary movements and facial grimacing, so A is correct. Answers B, C, and D describe other rheumatic fever symptoms but not chorea.
A 5-year old is admitted to the hospital with pneumonia. Her orders include chest physiotherapy, mist tent, and inhalation with Mucomyst (acetylcysteine). Which of the following measures should be included in her care?
- A. Telling her to breathe in through her nose and breathe out through her mouth
- B. Applying lotion to the exposed parts of her body
- C. Checking her clothing and linen frequently for dampness
- D. Obtaining a rectal temperature q 4 hours
Correct Answer: C
Rationale: Checking clothing and linen for dampness is necessary due to the mist tent, which can cause moisture buildup, leading to discomfort or skin issues.
A client taking isoniazid (INH) for tuberculosis asks the nurse about side effects of the medication. The client should be instructed to immediately report which of these?
- A. Double vision and visual halos
- B. Extremity tingling and numbness
- C. Confusion and lightheadedness
- D. Sensitivity of sunlight
Correct Answer: B
Rationale: Extremity tingling and numbness. Peripheral neuropathy is the most common side effect of INH and should be reported to the provider. It can be reversed.
A client with severe bilateral peripheral edema.
Which of the following is the BEST way for the nurse to determine the degree of edema in a limb, and the client's response to treatment?
- A. Measure both limbs with the tape measure and compare.
- B. Depress the skin and rank the degree of pitting.
- C. Describe the swelling in the affected area.
- D. Pinch the skin and note how quickly it returns to normal.
Correct Answer: B
Rationale: Strategy: Think about each answer choice. (1) is not the best way to evaluate for peripheral edema (2) correct-severity of edema is characterized by grading it 1+ (2-mm pitting) to 4+ (8-mm pitting) (3) not as objective (4) is used for evaluating hydration