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Which statement, from a participant attending the class on AIDS prevention, indicates an understanding on how to reduce transmission of HIV?
- A. Mother’s who are HIV positive should still be encouraged to breastfeed their babies because beast milk is superior to cow’s milk
- B. I think a needle exchange program, where clean needles are exchanged for dirty needles, should be offered in every city
- C. Females taking birth control pills are protected from getting HIV
- D. It’s okay to use natural skin condoms since they offer the same protection as the latex condoms
Correct Answer: B
Rationale: The correct answer is B. This statement shows an understanding of reducing HIV transmission by promoting harm reduction strategies like needle exchange programs, which help prevent sharing of contaminated needles. This approach is evidence-based and effective in reducing the spread of HIV among injection drug users.
Choice A is incorrect because breastfeeding by HIV-positive mothers can transmit the virus to infants. Choice C is incorrect as birth control pills do not protect against HIV, only against pregnancy. Choice D is incorrect as natural skin condoms do not provide the same level of protection against HIV as latex condoms do.
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The nurse is teaching a client who will be discharged soon how to change a sterile dressing on the right leg. During the teaching session, the nurse notices redness, swelling and induration at the wound site. What do these signs suggest?
- A. Infection
- B. Evisceration
- C. Dehiscence
- D. Hemorrhage
Correct Answer: A
Rationale: The presence of redness, swelling, and induration at the wound site are indicative of infection. Redness and swelling suggest inflammation, while induration indicates tissue hardening and can be a sign of infection spreading. Infection can delay healing and lead to complications if not treated promptly. Evisceration refers to wound opening with protrusion of internal organs, not indicated by the symptoms. Dehiscence is the partial or complete separation of wound layers, not represented by the symptoms. Hemorrhage involves excessive bleeding, which is not described in the scenario. Therefore, choice A is correct as it aligns with the signs observed and is the most appropriate response for the situation.
The nurse is teaching a class about breast self-examinations. A client asks if the she should have an annual mammogram. According to the American Cancer Society, how should the nurse respond?
- A. All women over age 30 should have an annual mammogram.
- B. All women over age 40 should have an annual mammogram.
- C. Any woman over age 20 whose mother had breast cancer should have an annual mammogram.
- D. Any woman who feels she is at risk for breast cancer should have an annual mammogram.
Correct Answer: B
Rationale: The correct answer is B: All women over age 40 should have an annual mammogram. The American Cancer Society recommends annual mammograms starting at age 40 for women with an average risk of breast cancer. This is based on evidence showing that regular mammograms starting at age 40 help in early detection and improve outcomes. Choice A is incorrect because the recommended age is 40, not 30. Choice C is incorrect as it focuses only on family history, while screening guidelines are based on overall risk factors. Choice D is incorrect because feeling at risk alone is not a sufficient indication for annual mammograms without considering other risk factors.
Which method of data collection will the nurse use to establish a patient’s database?
- A. Reviewing the current literature to determine evidence-based nursing actions
- B. Checking orders for diagnostic and laboratory tests
- C. Performing a physical examination
- D. Ordering medications
Correct Answer: C
Rationale: The correct answer is C: Performing a physical examination. This method allows the nurse to gather objective data directly from the patient's body, such as vital signs, appearance, and physical findings. It is essential for establishing a patient's baseline health status and identifying any abnormalities or changes. Reviewing literature (A) is important but not a method of data collection. Checking orders (B) is part of the assessment process but does not involve direct data collection. Ordering medications (D) is a clinical intervention and not a data collection method.
Which of the following signs indicates to the nurse that digoxin (Lanoxin) has been effective for a patient?
- A. Urine output decreases
- B. Heart rate higher than 95
- C. Urine output increases
- D. Heart rate lower than 50
Correct Answer: C
Rationale: The correct answer is C: Urine output increases. This indicates digoxin's effectiveness as it improves cardiac output by enhancing contraction strength. Increased urine output signifies improved kidney perfusion due to enhanced cardiac function. Option A is incorrect as decreased urine output indicates poor kidney perfusion. Option B is incorrect as digoxin aims to regulate heart rate, not necessarily make it higher than 95. Option D is incorrect as a heart rate lower than 50 could indicate digoxin toxicity.
Which of the ff nursing actions is helpful for older clients who are experiencing lens changes associated with aging?
- A. Offering teaching aids with larged-sized letters
- B. Suggesting reduced visual activity such as reading or watching television
- C. Suggesting use of eye drops for comfort
- D. Suggesting use of glasses or contact lenses CARING FOR CLIENTS WITH EYE DISORDERS
Correct Answer: D
Rationale: The correct answer is D, suggesting the use of glasses or contact lenses. This is because as older clients experience lens changes associated with aging, they may develop presbyopia or other vision issues that can be corrected with corrective lenses. Glasses or contact lenses can help improve their vision and quality of life.
A, offering teaching aids with large-sized letters, may be helpful for clients with visual impairments but may not directly address the specific lens changes associated with aging.
B, suggesting reduced visual activity, is not beneficial as it may further limit the client's engagement in daily activities and social interactions.
C, suggesting the use of eye drops for comfort, may provide temporary relief for dry eyes but does not address the underlying lens changes affecting vision.