A nurse has included the nursing diagnosis of Risk for Latex Allergy Response in a patient's plan of care. The presence of what chronic health problem would most likely prompt this diagnosis?
A) Herpes simplex
B) HIV
C) Spina bifida
D) Hypogammaglobulinemia
Ans: C
Feedback:
Patients with spina bifida are at a particularly high risk for developing a latex allergy. This is not true of patients with herpes simplex, HIV, or hypogammaglobulinemia.
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Which individual should receive further examination to determine the cause of the change in hair distribution?
a. 60-year-old male, who has lost all of the hair on his scalp over the past 15 years. b. 26-year-old female, who has experienced an increase of facial hair in the past year. c. 55-year-old male, who has developed coarse dark hairs in his ears and nose. d. 11-year-old girl, who has recently developed several dark hairs in her axillae and pubic area.
A client admitted for an asthma attack is also receiving psychiatric treatment for chronic schizophrenia
During the interview the client stops responding and says, "Why are you asking me all these questions? Why do you want to know? Are you recording this for the others?" The nurse's best response is a. "I am asking these questions as part of your hospital admission for asthma." b. "We cannot admit you without getting this information into our computers." c. "We will stop for now, but I'm going to report your behavior to your doctor." d. "Why are you asking me questions? This is part of the admission procedure."
Upon assessment of a client's wound, the nurse notes the formation of granulation tissue. The tissue easily bleeds when the nurse performs wound care. What is the phase of wound healing characterized by the nurse's assessment?
A) Proliferation phase B) Hemostasis C) Inflammatory phase D) Maturation phase
The nurse is assisting with a caloric test to determine if an alteration exists in the vestibular origin of the acoustic nerve. Which of the following accurately describes a step in this procedure?
A) Place the client in a prone position to perform the examination. B) Instill cold and/or warm water into the external ear canal. C) Test the affected side after testing the normal side. D) Replace water with hot air for a client with a punctured eardrum.