Nursing Process, Professional Behavior & Safety Week 1

Which sexually transmitted infection (STI) is most commonly reported? Syphilis Chlamydia Gonorrhea Human immunodeficiency virus

Chlamydia Rationale: Chlamydial infections are the most commonly reported STIs. Syphilis, human immunodeficiency virus, and gonorrhea are not the most commonly reported STIs.

Which manifestation indicates tertiary syphilis? Chancre Alopecia Gummas Condylomatalata

Gummas Rationale: Gummas are chronic, destructive lesions affecting the skin, bone, liver, and mucous membranes occur during tertiary syphilis. A chancre appears during primary syphilis. Alopecia and condylomata lata occur during secondary syphilis.

An adolescent visits the allergy clinic for testing. Which laboratory finding indicates that an allergic response is in progress? Decreased platelet count Increased eosinophil level Increased lymphocyte count Decreased immunoglobulin level

Increased eosinophil level Rationale: Eosinophils increase to inhibit the inflammatory response to histamine, which is released in allergic reactions. Platelets and lymphocytes are unrelated to allergic reactions. Immunoglobulins increase, not decrease, in response to an allergic reaction.

The nurse concludes that the teaching about sickle cell anemia has been understood when an adolescent with the disorder makes which statement? 'l'Il start to have symptoms when I drink less fluid.' 'lIl start to have symptoms when I have fewer platelets.' 'l'Il start to have symptoms when I decrease the iron in my diet. 'l'Il start to have symptoms when I have fewer white blood cells.

'l'Il start to have symptoms when I drink less fluid.' Rationale: Dehydration precipitates sickling of red blood cells and is a major causative factor for painful episodes associated with sickle cell anemia. An inadequate number of platelets (thrombocytes) is unrelated to painful episodes associated with sickle cell anemia. Iron intake is unrelated to the sickling phenomenon. An inadequate number of white blood cells is unrelated to painful episodes associated with sickle cell anemia.

Which education would the nurse provide the parent of a preschool-age child about how preschoolers view death? Universal Irreversible A form of sleep A frightening ghost

A form of sleep Rationale: Between the ages of 3 and 5 years, death is viewed as a departure or sleep and as reversible. The universality and irreversibility of death are concepts held by children starting at 8 to 9 years of age. The early school-age child of 6 or 7 years personifies death, possibly envisioning it as a ghost, and sees it as horrible and frightening; this is consistent with the concrete thinking present at this age.

The spouse of a client with pulmonary tuberculosis (TB) received a tuberculin skin test. The nurse examined the skin test and identified an area of induration greater than 10 mm. Which response to this finding would the nurse implement? No further action is required at this time. Additional tests are necessary to determine infection status. Immediately repeat the skin test for confirmation. Results are positive, indicating an active infection.

Additional tests are necessary to determine infection status. Rationale: The test does not indicate whether TB is dormant or active. However, a client with an induration of 5 mm or greater is considered positive. If there is repeated close contact with a person diagnosed with pulmonary TB or if the client has a disease causing decreased resistance, this requires further diagnostic study, such as chest x-rays and sputum culture. A newly infected client will receive preventive therapy with isoniazid (INH). Isoniazid will be continued for 6 months if chest x-rays are normal, or 12 months if chest x-rays are abnormal.Repeating the skin test is not necessary; the test is considered positive.

Which term would the nurse use in a report to describe the absence of menstrual periods in a 35-year-old nonpregnant client? Rhinorrhea Menopause Amenorrhea Dyspareunia

Amenorrhea Rationale: The absence of menstrual periods in a nonpregnant client younger than 55 years old is called amenorrhea. Rhinorrhea is an allergic state that is manifested by a runny nose. Menopause is cessation of menstruation after 55 years of age. Dyspareunia is pain during sexual intercourse.

Which disorder would the nurse classify as neurodevelopmental? Anxiety Bipolar disorder Schizophreniform disorder Attention-deficit/hyperactivity disorder

Attention-deficit/hyperactivity disorder Rationale: Neurodevelopmental disorders are a group of conditions with onset in the developmental period. Attention-deficit/hyperactivity disorder is a neurodevelopmental disorder. Anxiety, bipolar disorder, and schizophreniform disorder are not classified as neurodevelopmental.

Which component of delegation is the ability to perform duties in a specific role? Authority Responsibility Accountability Legal authority

Authority Rationale: Authority is the ability to perform duties in a specific role. Responsibility refers to reliability, dependability, and obligation to accomplish work. Accountability determines whether a person's actions are appropriate and provides a detailed explanation of what occurred. Legal authority is the ability to transfer selected nursing activities in a given situation to a competent individual.

Which product would the nurse instruct intravenous drug users (DUs) to use for cleaning of needles and syringes between uses? Bleach Hot water Ammonia Rubbing alcohol

Bleach Rationale: IDs should be instructed to fill syringes with household bleach and shake the syringe for 30 to 60 seconds. Hot water, ammonia, or rubbing alcohol is not used to disinfect used syringes.

Which term describes the practice of placing clients with the same infection in a semi-private room? Isolating Cohorting Colonizing Cross-referencing

Cohorting Rationale: Cohorting is the practice of grouping clients who are colonized or infected with the same pathogen. Isolating is limiting the exposure to individuals with an infection. Colonizing refers to the development of an infection in the body. Cross-referencing has nothing to do with an infectious process.

Which hormone is formed from cholesterol? Insulin Cortisol Prolactin Growth hormone

Cortisol Rationale: All lipid-soluble hormones are synthesized from cholesterol. Cortisol, a lipid-soluble hormone, is secreted by the adrenal cortex. All water-soluble hormones are formed from amino acids. Insulin, prolactin, and growth hormone are water-soluble hormones. Insulin is secreted by the pancreas. Prolactin and growth hormone are also secreted by the pituitary gland.

Which disorder is caused by the deficiency of antidiuretic hormone? Acromegaly Diabetes insipidus Cushing syndrome Syndrome of inappropriate antidiuretic hormone

Diabetes insipidus Rationale: Diabetes insipidus is caused by the deficiency of antidiuretic hormone. Acromegaly and Cushing syndrome are not associated with antidiuretic hormone; excessive production of growth hormone results in acromegaly and excessive production of adrenocorticotropic hormone causes Cushing syndrome. Syndrome of inappropriate antidiuretic hormone occurs as a result of increased production of antidiuretic hormone

Which component of the human personality, according to Freud, allows an individual to judge reality accurately? Id Ego Superego Oedipus complex

Ego Rationale: According to Freud, the ego allows an individual to judge reality accurately. The id is basic instinctual impulses driven to achieve pleasure. The superego is often referred to as the conscience. The Oedipus complex is a belief that a female child fantasizes about her father as a love interest.

Which characteristic is most essential for the nurse to have in caring for clients with mental health disorders? Empathy Sympathy Organization Authoritarianism

Empathy Rationale: Empathy-understanding and, to some extent, sharing the emotions of another- encourages the expression of feelings. Sympathy, or feeling sorry for someone, may further decrease the client's feelings of self-worth. Although organization may help the client accept limits and organize activities, it is not as important as empathy. An authoritarian approach will emphasize the client's weak ego and lack of self-esteem.

An adolescent girl is concerned about her body image after amputation of a leg for bone cancer. After the nurse has obtained the girl's consent, which action is most therapeutic? Encouraging her peers to visit Keeping her lower body covered Placing her in a room by herself Limiting her visitors to the family

Encouraging her peers to visit Rationale: Peer acceptance is crucial during this period; friends must have the opportunity to accept the client with one leg. Concealment does not help the adolescent or others accept the loss. Isolating the adolescent will increase feelings of alienation and being different. An adolescent needs to relate to and be accepted by peers and family.

Which sexually transmitted infection causes condylomata acuminate? Chlamydia Gonorrhea Herpes simplex Human papillomavirus (HPV)

Human papillomavirus (HPV) Rationale: Condylomata acuminate are genital warts that are caused by HPV. Genital warts are not caused by chlamydia, gonorrhea, or herpes simplex.

Which is the cause of milk anemia in toddlers? Drinking skim milk Drinking fruit juice Increased milk intake Increased intake of fruits

Increased milk intake Rationale: Toddlers who consume more than 24 ounces of milk daily in place of other foods sometimes develop milk anemia because milk is a poor source of iron. Children are usually not offered low-fat or skim milk until age 2 because they need the fat for satisfactory physical and intellectual growth. Toddlers need to drink whole milk until the age of 2 years to make sure that there is adequate intake of fatty acids necessary for brain and neurological development. Other solid food items are necessary for healthy growth and development in toddlers.

In the playroom of a pediatric unit, the nurse sees several toddlers seated at a table trying to copy the same picture from a book. They are not talking to each other or sharing their crayons. Which would the nurse conclude about this behavioral interaction? It is a typical expression of toddlers' social development. This is an example of antisocial behavior found in some children. It is a lack of parental role models to demonstrate acceptable behavior. This is an illustration of separation anxiety typical of hospitalized toddlers.

It is a typical expression of toddlers' social development. Rationale: As part of the socialization process, toddlers enjoy playing beside other children (parallel play); they are not developmentally ready for interactive (cooperative) play, which begins in the preschool years. This is not antisocial behavior; it is a misinterpretation of parallel play that is typical of toddlers' behavior. This is not an example of an ineffective parental role model; it is a misinterpretation of parallel play that is typical of toddlers' behavior. There are no data to indicate that the children are experiencing separation anxiety.

Which criteria would the nurse consider when determining if an infection is a health care- associated infection? Originated primarily from an exogenous source Is associated with a medication-resistant microorganism Occurred in conjunction with treatment for an illness Still has the infection despite completing the prescribed therapy

Occurred in conjunction with treatment for an illness Rationale: Health care-associated infections are classified as those that are contracted within a health care environment (e.g., hospital, long-term care facility) or result from a treatment (e.g., surgery, medications). Originating primarily from an exogenous source is not a criterion for identifying a health care-associated infection. The source of health care-associated infections may be endogenous (originate from within the client) or exogenous (originate from the health care environment or service personnel providing care); most health care-associated infections stem from endogenous sources and are caused by Escherichia coli and Staphylococcus aureus. Association with a medication-resistant microorganism is not a criterion for identifying a health care-associated infection. A health care-associated infection may or may not be caused by a medication-resistant microorganism. Still having the infection despite completing the prescribed therapy is not a criterion for identifying a health care-associated infection.

Why is a multiple-gestation pregnancy considered a high risk? Postpartum hemorrhage is an expected complication. Perinatal mortality is two to three times more likely in multiple than in single births. Optimal psychological adjustment after a multiple birth requires 6 months to 1 year. Maternal mortality is higher during the prenatal period in the setting of multiple gestation.

Perinatal mortality is two to three times more likely in multiple than in single births. Rationale: Perinatal morbidity and mortality rates are higher with multiple-gestation pregnancies, because the greater metabolic demands and the possibility of malpositioning of one or more fetuses increase the risk for complications. Although postpartum hemorrhage does occur more frequently after multiple births, it is not an expected occurrence. Adjustment to a multiple gestation and birth is individual; the time needed for adjustment does not place the pregnancy at high risk. Maternal mortality during the prenatal period is not increased in the presence of a multiple gestation.

The nurse is caring for a child who has an external fixation device on the leg. Which is the nurse's priority goal when providing pin care? Easing pain Minimizing scarring Preventing infection Preventing skin breakdown

Preventing infection Rationale: Pin sites provide a direct avenue for organisms into the bone. Pin care will not ease pain. Some scarring will occur at the pin insertion site regardless of pin site care. Skin has a tendency to grow around the pin, rather than break down, as long as infection is prevented.

Which team member acts as a liaison between the health care facility and the media? Triage officer Public information officer Medical command physician Hospital incident commander

Public information officer Rationale: The public information officer acts as a liaison between the health care facility and the media. The triage officer applies disaster triage tags after evaluating the client's condition. The medical command physician decides the number, acuity, and resource needs of clients. The hospital incident commander assumes overall leadership for implementing the emergency plan.

Which health care team member is responsible for analyzing the knowledge and work of newly hired unlicensed assistive personnel before delegating a task? Charge nurse Associate nurse Registered nurse (RN) Nursing manager

Registered nurse (RN) Rationale: The RN must analyze any individual's knowledge before delegating a task. The charge nurse mainly functions as a liaison between team leaders and other health care providers. The associate nurse follows the care plan in the absence of a RN. The nursing manager is responsible for more than 1 unit and has other managerial responsibilities.

The nurse instructs the parents of an adolescent with asthma on how to reduce the allergens in the child's bedroom. The mother tells the nurse what she plans to do to make the room hypoallergenic. Which idea indicates that further teaching is needed? Removing a stuffed animal collection Storing off-season clothing in another room Covering the mattress with a plastic slipcover Using flat outdoor carpeting to cover hardwood floors

Using flat outdoor carpeting to cover hardwood floors Rationale: Hardwood floors can be cleaned more easily than rugs can and are more hypoallergenic than outdoor carpeting. Stuffed toys are often sources of dust and mold. Out-of-season clothing harbors dust and should not be stored in the allergic child's room. Using a plastic slipcover reduces the child's exposure to dust generated by the mattress.