Nursing Elites

1. The client is being taught about the use of Rifampin for prophylaxis following exposure to meningitis. What change in bodily functions should the client be informed about?

• A. The client's urine may turn blue.
• B. The client remains infectious to others for 48 hours.
• C. The client's contact lenses may be stained orange.
• D. The client's skin may take on a crimson glow.

Correct answer: C

Rationale: Rifampin has the unusual effect of turning body fluids an orange color. Soft contact lenses might become permanently stained. Clients should be taught about these side effects to avoid unnecessary concern. Option A is incorrect as Rifampin does not cause the urine to turn blue. Option B is incorrect as the client is not infectious to others due to taking Rifampin for prophylaxis. Option D is incorrect as Rifampin does not cause the skin to take on a crimson glow.

2. A neighbor telephones the nurse to tell her that her child has erythema infectiosum and asks for information. The nurse knows that another name for the disorder is:

• A. Kawasaki disease
• B. rheumatic disease
• C. lupus erythematosus
• D. fifth disease

Correct answer: D

Rationale: The correct answer is 'fifth disease.' Erythema infectiosum, also known as fifth disease, is a parvovirus flu-like illness that is self-limiting but contagious for two to three weeks. Choice A, Kawasaki disease, is a different condition that involves inflammation of the blood vessels, predominantly affecting children. Choices B and C, rheumatic disease and lupus erythematosus, are also different conditions unrelated to erythema infectiosum.

3. Hearing screening of prematurely born infants is an effective means of identifying disease and is an example of:

• A. Primary prevention.
• B. Secondary prevention.
• C. Tertiary prevention.
• D. Disability prevention.

Correct answer: B

Rationale: The correct answer is B: Secondary prevention. Hearing screening for prematurely born infants falls under secondary prevention, which aims to identify and treat a condition in its early stages to prevent further complications. Primary prevention (choice A) focuses on preventing the disease from occurring, while tertiary prevention (choice C) involves managing complications and preventing disability. Choice D, disability prevention, is not a recognized category of prevention. In this context, the screening helps in early identification of hearing loss, allowing for timely intervention to prevent further impairment or complications, aligning with the principles of secondary prevention.

4. A Roman Catholic client is preparing to have magnetic resonance imaging. He wants to wear his metal crucifix pendant while he is receiving the test. Which of the following is an appropriate response by the nurse?

• A. "Because it gives you comfort, you may wear it."?
• B. "It is a violation of religious rights to forbid it."?
• C. "I am sorry, but it is not safe for you to wear the crucifix during this test."?
• D. "You may wear it because it is important to you."?

Correct answer: C

Rationale: No metal objects may be worn while receiving magnetic resonance imaging due to safety risks involved with the strong magnet. The correct response by the nurse should prioritize the safety of the client. Allowing the client to wear the metal crucifix poses a risk of injury or interference with the imaging process. Option A is not appropriate as safety takes precedence over comfort in this situation. Option B is incorrect as it does not address the safety concerns associated with wearing metal objects during an MRI. Option D is also incorrect as it fails to acknowledge the safety issue involved and instead focuses solely on the importance to the client. It is important for the nurse to offer alternative forms of spiritual support that do not pose a risk during the MRI procedure.

5. A nurse and a nursing assistant enter a client's room to provide care and find the client lying on the floor. Which action should the nurse take first?

• A. Ask the nursing assistant to complete an incident report
• B. Check the client's level of consciousness and vital signs
• C. Contact the unit secretary on the intercom and ask that the client's health care provider be called
• D. Ask the nursing assistant to assist in getting the client back to bed

Correct answer: B

Rationale: When a client sustains a fall, the nurse must first assess the client. The nurse should check the client's level of consciousness and vital signs to determine the severity of the situation and provide appropriate care promptly. This immediate assessment is crucial in ensuring the client's immediate needs are addressed. Asking the nursing assistant to complete an incident report (choice A) is not the priority as the client's condition needs immediate attention. Contacting the unit secretary to call the client's health care provider (choice C) can be done after the initial assessment has been completed. Asking the nursing assistant to assist in getting the client back to bed (choice D) should only be considered after ensuring the client is stable and safe to move.

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