the nursing process to deliver safe and effective patient-centered
care in medical-surgical settings
,Which instruction should the nurse teach a female client about the
prevention of toxic shock syndrome?
A. "Get immunization against HPV
B. "Change your tampon frequently"
C. "Empty your bladder after intercourse"
D. "Obtain a yearly flu vaccination
"Change your tampon frequently"
Rationale: Certain strains of Staphylococcus aureus produce a toxin
that can enter the bloodstream through the vaginal mucosa. Changing
the tampon frequently reduces the exposure to these toxins, which
are the primary cause of toxic shock syndrome. Option A helps
prevent cervical cancer, not toxic shock syndrome. Option C can
,lessen the incidence of urinary tract infection. Option D can help
prevent some individuals from contracting the flu and pneumonia, but
no relationship to toxic shock syndrome has been proven.
A client with hypertension has been receiving ramipril (Altace), 5 mg
PO, daily for 2 weeks and is scheduled to receive a dose at 0900. At
0830, the client's blood pressure is 120/70 mm Hg. Which action
should the nurse take?
Administer the prescribed dose at the scheduled time
Rationale: The client's blood pressure is within normal limits, indicating
that the ramipril, an antihypertensive, is having the desired effect and
should be administered
, The home health nurse is assessing a male client being treated for
Parkinson disease with carbidopa-levodopa. The nurse observes that
he does not demonstrate any apparent emotion when speaking and
rarely blinks. Which intervention should the nurse implement?
A. Perform a complete cranial nerve assessment
B. Instruct the client that he may be experiencing medication toxicity
C. Document the presence of these assessment findings
D. Advise the client to seek immediate medical evaluation
Document the presence of these assessment findings.
Rationale: A masklike expression and infrequent blinking are common
clinical features of parkinsonism. The nurse should document these
expected findings.
care in medical-surgical settings
,Which instruction should the nurse teach a female client about the
prevention of toxic shock syndrome?
A. "Get immunization against HPV
B. "Change your tampon frequently"
C. "Empty your bladder after intercourse"
D. "Obtain a yearly flu vaccination
"Change your tampon frequently"
Rationale: Certain strains of Staphylococcus aureus produce a toxin
that can enter the bloodstream through the vaginal mucosa. Changing
the tampon frequently reduces the exposure to these toxins, which
are the primary cause of toxic shock syndrome. Option A helps
prevent cervical cancer, not toxic shock syndrome. Option C can
,lessen the incidence of urinary tract infection. Option D can help
prevent some individuals from contracting the flu and pneumonia, but
no relationship to toxic shock syndrome has been proven.
A client with hypertension has been receiving ramipril (Altace), 5 mg
PO, daily for 2 weeks and is scheduled to receive a dose at 0900. At
0830, the client's blood pressure is 120/70 mm Hg. Which action
should the nurse take?
Administer the prescribed dose at the scheduled time
Rationale: The client's blood pressure is within normal limits, indicating
that the ramipril, an antihypertensive, is having the desired effect and
should be administered
, The home health nurse is assessing a male client being treated for
Parkinson disease with carbidopa-levodopa. The nurse observes that
he does not demonstrate any apparent emotion when speaking and
rarely blinks. Which intervention should the nurse implement?
A. Perform a complete cranial nerve assessment
B. Instruct the client that he may be experiencing medication toxicity
C. Document the presence of these assessment findings
D. Advise the client to seek immediate medical evaluation
Document the presence of these assessment findings.
Rationale: A masklike expression and infrequent blinking are common
clinical features of parkinsonism. The nurse should document these
expected findings.
