Nokea
Which response by the nurse provides the best clarification about the disease process?
- A. If you're afraid of getting HIV, you'll be safer if you avoid having sex with past sex partners.
- B. An HIV-positive individual may not develop symptoms of AIDS for years.
- C. HIV can only be transmitted when symptoms of AIDS are present.
- D. The medication prescribed for AIDS also protects against HIV infection.
Correct Answer: B
Rationale: HIV can be asymptomatic for years, during which it is still transmissible, making this clarification critical for understanding the disease process and transmission risk.
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Which nursing action would best promote the adolescent's compliance with wearing the brace?
- A. Advising the parents to keep a constant watch on their daughter to make sure she wears her brace
- B. Suggesting that the parents help their daughter find stylish clothing that will hide the brace
- C. Telling the parents that it might be best to arrange for a homebound teacher
- D. Advising the parents to limit their daughter's participation in school activities
Correct Answer: B
Rationale: Helping the adolescent find stylish clothing to conceal the brace addresses body image concerns, promoting compliance by making the brace less noticeable.
Calculating from the date of the mother’s last menstrual period,the nurse determines that her newborn’s gestational age is 40 weeks. Which normal findings should the nurse expect when assessing this newborn at birth? Select all that apply.
- A. Hypertonic flexion of all extremities.
- B. Sole creases on the anterior two-thirds of the sole.
- C. Well-defined incurving of the entire ear pinna.
- D. Presence of a prominent clitoris.
- E. Infant is able to support the head momentarily when pulled to a sitting position.
Correct Answer: A,C,E
Rationale: Full-term newborns (40 weeks) exhibit hypertonic flexion well-defined ear pinna incurving and momentary head support. Sole creases over two-thirds indicate ~37 weeks and a prominent clitoris is seen at 30–32 weeks.
The nurse is discharging the 3-day-old term newborn with a right-sided cephalohematoma. The nurse should instruct the parents to observe their infant closely over the next week for the development of which problem associated with the cephalohematoma?
- A. Jaundice
- B. Difficulty feeding
- C. Pale extremities
- D. Bulging on the right side of the head with crying
Correct Answer: A
Rationale: Cephalohematoma resolution causes RBC hemolysis leading to jaundice. It doesn’t affect feeding cause paleness or bulge with crying.
Which statement by the client indicates a need for additional teaching about genital herpes?
- A. Males who have genital herpes need a yearly prostate-specific antigen (PSA) test.
- B. Females who have genital herpes need a Papanicolaou (Pap) test every 6 months.
- C. Genital herpes is closely associated with the occurrence of sterility.
- D. Genital herpes is closely associated with Hodgkin's disease.
Correct Answer: A
Rationale: Genital herpes is not associated with a need for yearly PSA tests in males, indicating a misconception. Regular Pap tests may be recommended for females due to increased cervical cancer risk with certain STIs, but the PSA statement is incorrect.
Which of the following is the priority nursing action if the child shows symptoms of hypoglycemic reaction?
- A. Give the child orange juice or milk to drink.
- B. Give the child 10% glucose I.V.
- C. Notify the physician immediately.
- D. Administer a second dose of insulin.
Correct Answer: A
Rationale: For hypoglycemia, the priority is to rapidly raise blood glucose. Giving orange juice or milk provides quick-acting carbohydrates, the first-line treatment for conscious patients with mild to moderate hypoglycemia.