Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is planning care for a client who has primary syphilis. Which of the following actions should the nurse take?
A. Monitor the client for hearing loss.
Monitoring for hearing loss is not a specific action for primary syphilis. Hearing loss can occur in later stages of syphilis.
B. Use contact precautions when caring for the client.
Contact precautions are not typically required for primary syphilis, as it is primarily transmitted through sexual contact.
C. Administer an antiviral medication to the client.
Antiviral medications are not used to treat syphilis. Antibiotics are the primary treatment.
D. Report the infection to the public health department.
Syphilis is a sexually transmitted infection that is required to be reported to the public health department for tracking and control.
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Full Explanation
Choice A rationale:
Monitoring for hearing loss is not a specific action for primary syphilis. Hearing loss can occur in later stages of syphilis.
Choice B rationale:
Contact precautions are not typically required for primary syphilis, as it is primarily transmitted through sexual contact.
Choice C rationale:
Antiviral medications are not used to treat syphilis. Antibiotics are the primary treatment.
Choice D rationale:
Syphilis is a sexually transmitted infection that is required to be reported to the public health department for tracking and control.
Similar Questions
A nurse is planning care for a client who has leukemia and is prescribed bed rest. Which of the following interventions should the nurse include in the plan?
A. Have the client perform pulmonary hygiene every 8 hr.
Pulmonary hygiene is important, but it is not the priority for a client on bed rest with leukemia.
B. Place the client on airborne precautions.
Airborne precautions are not necessary for leukemia, which is not an airborne-transmitted disease.
C. Turn the client every 4 hr and apply powder to moist areas.
Turning the client every 4 hours helps prevent pressure ulcers and applying powder to moist areas helps maintain skin integrity.
D. Assess the client's urine for odor and cloudiness.
Assessing urine for odor and cloudiness is not specific to the care needs of a client with leukemia on bed rest.
Full Explanation
- Rationale for Choice A: Pulmonary hygiene is important for preventing pneumonia, especially in bedridden clients. However, it is not specific to the care of a client with leukemia unless they have a respiratory complication which necessitates such an intervention.
- Rationale for Choice B: Airborne precautions are typically used for clients who have infections that can be transmitted through the air, such as tuberculosis. Leukemia does not require airborne precautions unless the client has a coexisting airborne infection.
- Rationale for Choice C: Regular turning of the client can help prevent pressure ulcers and is a good practice for any bedridden patient. However, the use of powder is controversial as it can cake and lead to skin breakdown, and is not specifically indicated for leukemia care.
- Rationale for Choice D: Assessing the client's urine for odor and cloudiness is an important part of care for clients with leukemia. They are at increased risk for urinary tract infections due to immunosuppression, and changes in urine can indicate an infection that needs prompt treatment.
A nurse is assessing a client who is 4 hr postoperative following a craniotomy for the treatment of a benign brain tumor. Which of the following findings should the nurse identify as the priority?
A. 15 mL of drainage in Hemovac
Drainage in the Hemovac is an expected finding postoperatively and is not as urgent as nonreactive pupils.
B. Periorbital ecchymosis
Periorbital ecchymosis (bruising around the eyes) is not uncommon after a craniotomy and is not as urgent as nonreactive pupils.
C. Nonreactive pupils
Nonreactive pupils can indicate a neurological emergency, such as increased intracranial pressure or potential damage to the cranial nerves. This finding requires immediate attention to prevent further complications.
D. Hgb 11 g/dL
Hemoglobin level of 11 g/dL is within a normal range and is not a priority concern.
Full Explanation
Choice A rationale:
Drainage in the Hemovac is an expected finding postoperatively and is not as urgent as nonreactive pupils.
Choice B rationale:
Periorbital ecchymosis (bruising around the eyes) is not uncommon after a craniotomy and is not as urgent as nonreactive pupils.
Choice C rationale:
Nonreactive pupils can indicate a neurological emergency, such as increased intracranial pressure or potential damage to the cranial nerves. This finding requires immediate attention to prevent further complications.
Choice D rationale:
Hemoglobin level of 11 g/dL is within a normal range and is not a priority concern.
A nurse is speaking with a client who is experiencing a situational crisis following the sudden death of his partner. Which of the following questions should the nurse ask the client first?
A. "Who do you talk to when you feel overwhelmed?"
Asking who the client talks to when overwhelmed is important, but assessing for suicidal thoughts is more urgent.
B. "Are you thinking about harming yourself?"
Assessing the client's risk for harm to themselves is the priority when dealing with a person in crisis. This helps determine the need for immediate intervention to ensure their safety.
C. "Can we talk about how your partner's death has affected you?"
Discussing the impact of the partner's death can be therapeutic, but ensuring immediate safety is the priority.
D. "What do you usually do to calm your thoughts?"
Inquiring about coping strategies is important, but assessing for suicidal thoughts takes precedence.
Full Explanation
Choice A rationale:
Asking who the client talks to when overwhelmed is important, but assessing for suicidal thoughts is more urgent.
Choice B rationale:
Assessing the client's risk for harm to themselves is the priority when dealing with a person in crisis. This helps determine the need for immediate intervention to ensure their safety.
Choice C rationale:
Discussing the impact of the partner's death can be therapeutic, but ensuring immediate safety is the priority.
Choice D rationale:
Inquiring about coping strategies is important, but assessing for suicidal thoughts takes precedence.