Nokea
Which of the following nursing measures is most appropriate to meet the expected outcome of positive body image?
- A. administering immune globulin intravenously
- B. assessing the extremities for edema, redness and desquamation every 8 hours
- C. explaining progression of the disease to the client and his or her family
- D. assessing heart sounds and rhythm
Correct Answer: C
Rationale: Teaching the client and family about progression of the disease includes explaining when symptoms can be expected to improve and resolve. Knowledge of the course of the disease can help them understand that no permanent disruption in physical appearance will occur that could negatively affect body image. Clients with Kawasaki disease might receive immune globulin intravenously to reduce the incidence of coronary artery lesions and aneurysms. Cardiac effects could be linked to body image, but Choice 3 is the most direct link to body image. The nurse assesses symptoms to assist in evaluation of treatment and progression of the disease.
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All of the following factors, when identified in the history of a family, are correlated with poverty except:
- A. high infant mortality rate.
- B. frequent use of Emergency Departments.
- C. consultation with folk healers.
- D. low incidence of dental problems.
Correct Answer: D
Rationale: Dental problems are prevalent because of the lack of preventive care and access to care. High infant mortality is one of the most significant problems correlated with poverty. Pregnant women who do not have access to care might come to the Emergency Department when in labor. Those in poverty are likely to use Emergency Departments because they may not be turned away. Those in poverty might also turn to folk healers or other persons in their community for care who might be easier to access and might not demand payment.
A nurse is instructing a patient about the warning signs of (Digitalis) side effects. Which of the following side effects should the nurse tell the patient are sometimes associated with excessive levels of Digitalis?
- A. Seizures
- B. Muscle weakness
- C. Depression
- D. Anxiety
Correct Answer: B
Rationale: Palpitations and muscle weakness are found with excessive levels of Digitalis, as they are signs of toxicity.
Which of the following methods of contraception is able to reduce the transmission of HIV and other STDs?
- A. intrauterine device (IUD)
- B. Norplant
- C. oral contraceptives
- D. vaginal sponge
Correct Answer: D
Rationale: The vaginal sponge is a barrier method of contraception that, when used with foam or jelly contraception, reduces the transmission of HIV and other STDs as well as reducing the risk of pregnancy. IUDs, Norplant, and oral contraceptives can prevent pregnancy but not the transmission HIV and STDs. Clients using the contraceptive methods in Choices A, B, and C should be counseled to use a chemical or barrier contraceptive to decrease transmission of HIV or STDs.
The nurse has a client who is being transferred to another floor right around change of shift. Which of the following actions is least appropriate?
- A. Inform the staff on the other floor of any unresolved issues with the client.
- B. Ask the charge nurse if overtime would be permitted to complete the client's transfer to the other floor.
- C. Ask the new nurse to take care of the transfer since the client's medical record has all of the information and a report should not be needed.
- D. Complete the transfer paperwork before the client is transferred.
Correct Answer: C
Rationale: The nurse should ensure a safe handoff of care during the transfer. The nurse on the next shift should not be asked to complete the transfer for the client without a full handoff of care.
The nurse is working the same shift two days in a row. On the first of these days, while caring for one assigned client, the client says, 'Will you promise me you will be my nurse tomorrow?' Which response is most appropriate.
- A. Yes, I promise you I will be your nurse during my shift tomorrow.'
- B. You will need to speak to my supervisor about this request.'
- C. While I cannot promise that I will be your nurse tomorrow, I can talk to the charge nurse about this request.'
- D. Because of confidentiality, I cannot discuss tomorrow's assignments with you.'
Correct Answer: C
Rationale: While the nurse should not make any promises to the client, they can attempt to accommodate this request by speaking with their supervisor.