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The nurse participating in a health fair is setting up a booth on prevention of human immunodeficiency virus (HIV) transmission. A poster is planned that will list sexual behaviors in 1 of 2 columns, "safe" and "not safe." Which behavior should the nurse place in the "not safe" column? 1. Abstinence 2. Mutual monogamy 3. Use of latex condoms 4. Use of natural skin condoms
Rationale: Abstinence is the safest way to avoid HIV infection. Another reliable method is participation in a mutually monogamous relationship. The use of latex condoms is considered safe because the latex prevents the transmission of HIV as long as the condom is used properly and remains in place. The use of natural skin condoms is not considered safe because the pores in the condom are large enough for the virus to pass through.
A client who has had a prostatectomy is complaining of pain from bladder spasms. The nurse checks the health care provider's prescription sheet and expects to see which medication prescribed to treat the problem? 1. Oxybutynin 2. Hydromorphone 3. Morphine sulfate 4. Meperidine hydrochloride
Rationale: Bladder spasms after prostatectomy are treated with antispasmodic medications, such as oxybutynin. Opioid analgesics such as morphine sulfate, hydromorphone, and meperidine hydrochloride usually are not effective in treating pain caused by spasms.
A pregnant client tells the clinic nurse that she wants to know the sex of her baby as soon as it can be determined. The nurse informs the client that she should be able to find out the sex at 12 weeks' gestation because of which factor? 1. The appearance of the fetal external genitalia 2. The beginning of differentiation in the fetal groin 3. The fetal testes are descended into the scrotal sac 4. The internal differences in males and females become apparent
Rationale: By the end of the twelfth week, the external genitalia of the fetus have developed to such a degree that the sex of the fetus can be determined visually. Differentiation of the external genitalia occurs at the end of the ninth week. Testes descend into the scrotal sac at the end of the thirty-eighth week. Internal differences in the male and female occur at the end of the seventh week.
The nurse is conducting home visits with a head-injured client with residual cognitive deficits. The client has problems with memory, has a shortened attention span, is easily distracted, and processes information slowly. The nurse plans to talk with the primary health care provider about referring the client to which professional? 1. A psychologist 2. A social worker 3. A neuropsychologist 4. A vocational rehabilitation specialist
Rationale: Clients with cognitive deficits after head injury may benefit from referral to a neuropsychologist, who specializes in evaluating and treating cognitive problems. The neuropsychologist plans an individual program of therapy and initiates counseling to help the client reach maximal potential. The neuropsychologist works in collaboration with other disciplines that are involved in the client's care and rehabilitation. The remaining options are incorrect because these health care workers do not specialize in evaluating and treating cognitive problems.
The nurse caring for an Orthodox Jewish client plans a diet that adheres to the practices of the client's faith. When planning care, the nurse recognizes that which principles are consistent with dietary kosher laws? Select all that apply. 1. Meat and milk can be eaten together. 2. Eating fish with scales and fins is allowed. 3. Unleavened bread is eaten during Passover week. 4. Meat from animals that are vegetable eaters is allowed. 5. Meat is allowed if the food animal is ritually slaughtered.
Rationale: Dietary kosher laws must be adhered to by Orthodox believers. Meats allowed include animals that are vegetable eaters, cloven-hoofed animals, and animals that are ritually slaughtered. Fish that have scales and fins are allowed; however, any combination of meat and milk is prohibited. During Passover week, only unleavened bread is eaten.
A nursing student is doing a presentation on human papillomavirus (HPV) for a young adult group aged 18 to 20 years old. What information should the nursing student include in this presentation? Select all that apply. 1. "Some forms of HPV can lead to cervical cancer." 2. "You cannot get HPV if you have had only 1 sex partner." 3. "There are no vaccinations available to protect against HPV." 4. "HPV is most commonly spread during vaginal or anal sexual contact." 5. "In some types, HPV will go away on its own and does not cause health issues."
Rationale: HPV has now become the most common sexually transmitted infection. Some types of HPV have been found to have a strong link to cervical cancer, while other types of HPV may resolve without any intervention. HPV may be contracted with any sexual partner. There is a vaccine for the known strains that may lead to cervical cancer, which can be administered to females from ages 9 to 26 years. HPV is spread through vaginal or anal sexual contact.
Which additional daily dietary intake will most closely match the number of additional calories needed by the breast-feeding mother? 1. Apple and orange 2. Peanut butter and jelly sandwich and glass of 2% milk 3. Hamburger with bun, French fries, and glass of skim milk 4. 4-ounce (113 gm) grilled chicken breast, sweet potato, and 16-ounce (475 ml) milkshake
Rationale: If the client is breast-feeding, her calorie needs increase by approximately 500 calories/day. Adding only an apple and an orange will be too few calories. The hamburger meal and the chicken breast meal contain significant calories over the required 500 calories.
The nurse is checking lochia discharge in a woman in the immediate postpartum period. The nurse notes that the lochia is bright red and contains some small clots. Based on these data, the nurse should make which interpretation? 1. The client is hemorrhaging. 2. The client needs to increase oral fluids. 3. The client is experiencing normal lochia discharge. 4. The client's health care provider (HCP) needs to be notified of the finding.
Rationale: Lochia, the uterine discharge present after birth, initially is bright red and may contain small clots. During the first 2 hours after birth, the amount of uterine discharge should be approximately that of a heavy menstrual period. After that time, the lochial flow should steadily decrease, and the color of the discharge should change to a pinkish red or reddish brown. Because this is a normal, expected occurrence, the client is not hemorrhaging and not in need of increased fluids and there is no need to contact the HCP.
The client in the preoperative holding area has been given a dose of scopolamine. Which intended effect is this medication likely being used for with this client? Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Nursing Process: Evaluation Content Area: Pharmacology: Gastrointestinal Medications Strategy(ies): Subject Priority Concepts: Clinical Judgment, Safety 1. Obstetric amnesia 2. Suppression of emesis 3. Preanesthetic amnesia 4. Production of cycloplegia
Rationale: Scopolamine is an anticholinergic medication that can be used preoperatively. While all options are indications and therapeutic effects of this medication, preanesthetic amnesia is the intended effect in this situation.
The clinic nurse is providing instructions to a client with diabetes mellitus about the signs and symptoms of hypoglycemia. The nurse should tell the client that which would be noted in a hypoglycemic reaction? 1. Thirst 2. Hunger 3. Polydipsia 4. Increased urine output
Rationale: Signs and symptoms of hypoglycemia include hunger, nervousness, anxiety, dizziness, blurred vision, sweaty palms, confusion, and tingling and numbness around the mouth. Polydipsia (thirst) and increased urine output are noted in the client with hyperglycemia.
A nulliparous woman asks the nurse when she will begin to feel fetal movements. The nurse responds by telling the woman that the first recognition of fetal movement will occur at approximately how many weeks of gestation? 1. 5 weeks 2. 9 weeks 3. 13 weeks 4. 18 weeks
Rationale: The first recognition of fetal movements, or feeling life, by the multiparous woman may occur as early as 14 to 16 weeks' gestation. The nulliparous woman may not notice these sensations until 18 weeks' gestation or later, as she has no prior experience and the uterus has not been previously stretched during pregnancy adaptation. The first recognition of fetal movement is called quickening.
A client has frequent bursts of ventricular tachycardia on the cardiac monitor. What should the nurse be most concerned about with this dysrhythmia? 1. It can develop into ventricular fibrillation at any time. 2. It is almost impossible to convert to a normal rhythm. 3. It is uncomfortable for the client, giving a sense of impending doom. 4. It produces a high cardiac output that quickly leads to cerebral and myocardial ischemia.
Ventricular tachycardia is a life-threatening dysrhythmia that results from an irritable ectopic focus that takes over as the pacemaker for the heart. The low cardiac output that results can lead quickly to cerebral and myocardial ischemia. Clients frequently experience a feeling of impending doom. Ventricular tachycardia is treated with antidysrhythmic medications, cardioversion (if the client is awake), or defibrillation (loss of consciousness). Ventricular tachycardia can deteriorate into ventricular fibrillation at any time.
The nurse is conducting a neurological assessment, including a health history, on a client with a neurological disorder. The nurse observes that the client is having difficulty answering the questions and should perform which action? 1. Ask a second nurse to be present during the interview. 2. Defer both the health history and the neurological examination. 3. Defer the health history and proceed with the neurological examination. 4. Ask the client to give permission for a family member to stay during the interview.
he health history and physical assessment for a client with a neurological problem are very similar to those for any other client, with perhaps a more intense neurological examination. If the client is confused or agitated or has difficulty hearing or speaking, the nurse should ask the client to give permission for a family member or significant other to stay with him or her during the history taking to ensure accurate data. Deferring the health history and/or neurological examination will not obtain the assessment data. Having a second nurse present is of no benefit.
