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A nurse in a family health clinic is caring for a client who requests information regarding the correct use of condoms.
Which of the following statements should the nurse make?
- A. When using implanted contraceptive methods, condoms should also be used to protect against STDs.
- B. Use of petroleum-based lubricant with a condom increases the condom's effectiveness
- C. Ensure that the condom fits snugly over the tip of the penis
- D. Condoms are equally effective for birth control with or without the use of vaginal spermicides
Correct Answer: A
Rationale: The correct answer is A. This statement is correct because implanted contraceptive methods, like hormonal implants, do not protect against sexually transmitted diseases (STDs), so using condoms is necessary for dual protection. Choice B is incorrect as petroleum-based lubricants can weaken condoms. Choice C is incorrect because a condom should fit comfortably, not snugly, to prevent breakage. Choice D is incorrect because condoms are more effective for birth control when used with spermicide.
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A nurse is assessing a client who has bipolar disorder and is experiencing a depressive episode.
Which finding should the nurse expect?
- A. Move quickly from one idea to the next
- B. Feelings of hopelessness or worthlessness
- C. Decreased energy and fatigue
- D. Difficulty concentrating or making decisions
- E. Changes in appetite, either increased or decreased
Correct Answer: B
Rationale: The correct answer is B: Feelings of hopelessness or worthlessness. This is a key symptom of depression and is often present in individuals experiencing a depressive episode. It is important for the nurse to recognize this as it can indicate a serious mental health issue that requires intervention. Choices A, C, D, and E are also common symptoms of depression, but they are not as specific to the core of the condition as feelings of hopelessness or worthlessness. Moving quickly from one idea to the next (A) may suggest mania or hypomania rather than depression. Decreased energy and fatigue (C), difficulty concentrating or making decisions (D), and changes in appetite (E) are also common in depression, but they are not as indicative of the deep emotional distress associated with feelings of hopelessness or worthlessness.
A nurse enters a client's room and sees a small fire in the client's bathroom.
Identify the sequence of steps the nurse should take?
- A. Close all nearby windows and doors
- B. Transport the client to another area of the nursing unit
- C. Use the unit's fire extinguisher to attempt to put out the fire
- D. Activate the facility's fire alarm system
Correct Answer: D
Rationale: The correct answer is D: Activate the facility's fire alarm system. This is the first step the nurse should take in case of a fire emergency to ensure the safety of all individuals in the facility. Activating the fire alarm alerts everyone in the building about the fire and prompts an immediate response from the fire department. Closing windows and doors (A) may help contain the fire but should not be the initial action. Transporting the client (B) could put them at risk and is not a priority. Using the fire extinguisher (C) should only be done if safe and appropriate, but activating the alarm is more crucial.
A nurse is caring for an infant who has coarctation of the aorta.
Which finding should the nurse identify as expected?
- A. Weak femoral pulses
- B. Bounding pulses in the lower extremities
- C. Cyanosis of the hands and feet
- D. Frequent episodes of bradycardia
Correct Answer: A
Rationale: The correct answer is A: Weak femoral pulses. In pediatric patients, weak femoral pulses are expected due to the normal physiological differences in vascular resistance between upper and lower extremities. This is known as the "femoral pulse lag." Bounding pulses in the lower extremities (choice B) would be abnormal and could indicate a vascular disorder. Cyanosis of the hands and feet (choice C) suggests poor perfusion and oxygenation, which is concerning. Frequent episodes of bradycardia (choice D) could indicate cardiac issues and are not expected in a healthy pediatric patient.
A school nurse is teaching a parent about absence seizures.
Which information should the nurse include?
- A. This type of seizure can be mistaken for daydreaming
- B. Absence seizures typically last only a few seconds.
- C. The child may not remember the seizure episode afterward.
- D. There are usually no warning signs before an absence seizure occurs.
- E. Lip smacking or eye fluttering may accompany the seizure.
Correct Answer: E
Rationale: The correct answer is E because lip smacking or eye fluttering are common manifestations of absence seizures, providing crucial information for recognition and diagnosis. Choice A is incorrect as it does not specifically relate to absence seizures. Choice B is incorrect because absence seizures typically last 10-20 seconds, not just a few seconds. Choice C is incorrect as individuals experiencing absence seizures usually do not have memory issues afterward. Choice D is incorrect because some individuals may have warning signs before an absence seizure.
A nurse is caring for a client who is receiving radiation therapy and is experiencing anorexia.
Which of the following actions should the nurse take?
- A. Provide the client with cold foods rather than hot foods
- B. Encourage the client to drink fluids with meals
- C. Offer the client large meals three times a day
- D. Advise the client to avoid high-protein foods
Correct Answer: A
Rationale: The correct answer is A because providing the client with cold foods rather than hot foods can help reduce nausea and vomiting, which are common symptoms of pregnancy. Cold foods are generally better tolerated by pregnant women experiencing morning sickness. Encouraging the client to drink fluids with meals (choice B) is important, but it is not the most immediate action to alleviate nausea. Offering the client large meals three times a day (choice C) may worsen nausea, as smaller, more frequent meals are typically recommended. Advising the client to avoid high-protein foods (choice D) is not necessary unless there are specific contraindications, as protein is important for fetal development.