Nursing Elites

1. A female client diagnosed with genital herpes simplex virus 2 (HSV 2) complains of dysuria, dyspareunia, leukorrhea, and lesions on the labia and perianal skin. A primary nursing action with the focus of comfort should be to

• A. Suggest 3 to 4 warm sitz baths per day
• B. Cleanse the genitalia twice a day with soap and water
• C. Spray warm water over genitalia after urination
• D. Apply heat or cold to lesions as desired

Correct answer: A

Rationale: The correct answer is to suggest 3 to 4 warm sitz baths per day. Warm sitz baths can soothe the irritated genital area, reduce pain, and promote healing of the lesions associated with genital herpes. Cleansing the genitalia with soap and water or spraying warm water over the genitalia after urination may further irritate the lesions. Applying heat or cold to lesions as desired may not provide the same level of comfort and healing as warm sitz baths.

2. You are teaching a client about the patient-controlled analgesia (PCA) planned for post-operative care. Which statement indicates further teaching may be needed by the client?

• A. ''I will be receiving continuous doses of medication.''
• B. ''I should call the nurse before I take additional doses.''
• C. ''I will call for assistance if my pain is not relieved.''
• D. ''The machine will prevent an overdose.''

Correct answer: B

Rationale: PCA allows patients to self-administer pain medication within prescribed limits, without the need to call the nurse before taking an additional dose. Choice B suggests a misunderstanding of how PCA works, as the patient should be educated that they can self-administer doses within the safety parameters set by the healthcare provider. Choices A, C, and D demonstrate proper understanding of PCA, hence are not indicative of needing further teaching.

3. The nurse is teaching a group of older adults about medication safety. Which of the following should be included in the teaching?

• A. keeping a list of all medications and dosages
• B. sharing medications with family members if they have the same prescription
• C. stopping medications when symptoms improve
• D. doubling up on missed doses

Correct answer: A

Rationale: The correct answer is A: keeping a list of all medications and dosages. Maintaining a comprehensive list of medications and their dosages is essential for older adults to prevent medication errors and dangerous interactions. Choice B is incorrect because sharing medications, even if family members have the same prescription, can lead to unintended adverse effects or inappropriate dosages. Choice C is incorrect as stopping medications when symptoms improve can be harmful if the full course of treatment is not completed. Choice D is incorrect as doubling up on missed doses can result in overdosing and adverse reactions.

4. In evaluating your client's level of wellness, which of the following indicators can you see?

• A. Appropriate nutritional level
• B. Sense of personal security
• C. Acceptance of oneself and one's limitations
• D. Maladaptations to one's environment

Correct answer: C

Rationale: When evaluating a client's level of wellness, indicators such as appropriate nutritional level, sense of personal security, and acceptance of oneself and one's limitations are crucial. Option C, 'Acceptance of oneself and one's limitations,' directly relates to mental wellness and self-awareness, making it a key indicator of overall well-being. Options A, B, and D are not as directly tied to the psychological and emotional aspects of wellness, making them less relevant indicators in this context. Therefore, the correct answer is C.

5. A female client makes routine visits to a neighborhood community health center. The nurse notes that this client often presents with facial bruising, particularly around the eyes. The nurse discusses prevention of domestic violence with the client even though the client does not admit to being battered. What level of prevention has the nurse applied in this situation?

• A. primary prevention
• B. secondary prevention
• C. tertiary prevention
• D. health promotion

Correct answer: B

Rationale: The correct answer is B: secondary prevention. Secondary prevention involves identifying and addressing issues early to prevent further harm. In this scenario, the nurse is intervening by discussing domestic violence prevention with the client who is showing signs of facial bruising, aiming to prevent further harm even though the client has not disclosed being battered. Choice A (primary prevention) focuses on preventing the onset of a problem before it occurs, like educating about healthy relationships before violence happens. Choice C (tertiary prevention) involves managing and treating the effects of a problem that has already occurred, such as providing counseling to a domestic violence survivor. Choice D (health promotion) aims to enhance well-being and prevent health problems through educational and environmental interventions, which may include aspects of preventing domestic violence, but in this case, the nurse's direct intervention is more about early identification and prevention of harm, aligning it with secondary prevention.

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