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A nurse in the emergency department is assessing an adolescent who reports sudden and severe testicular pain. Which of the following actions should the nurse take?
A nurse is providing education to a 16-year-old client who is being prescribed zidovudine (Retrovir) as antiretroviral therapy (ART) for HIV. Which of the following statements should the nurse include in the teaching?
A nurse is providing education to the family of a school-aged child who has a history of atrial septal defect (ASD) with surgical repair. The child's caregivers ask the nurse if their child can play sports. Which of the following statements made by the nurse is most appropriate?
A nurse is caring for a 3-year-old client who has been diagnosed with acute cystitis and is prescribed cephalexin. Which of the following pathogens should the nurse identify as the most common bacterial cause of UTIs?
A nurse is caring for a preschool-aged child whose parent asks how to get their child to eat healthier food. Which of the following responses should the nurse make?
A nurse is teaching a newly hired nurse about the risks of cellulitis following an injury. Which of the following statements by the newly hired nurse shows the teaching was effective?
A nurse is preparing to assess reflexes in a 3-day-old newborn who is currently asleep. Which reflex is most appropriately tested during the newborn's sleep state to evaluate neurological function?
A nurse is caring for a 12-year-old client in the acute phase of HIV. Which complication should the nurse monitor for at this time?
A nurse is educating the parents of a 3-year-old child who has autism spectrum disorder (ASD). Which of the following patterns of behavior should the nurse include in the teaching? (Select all that apply.)
A. Fixation on certain items or topics
Children with ASD often exhibit intense focus or preoccupation with specific objects, interests, or topics, which is a hallmark of repetitive and restricted behaviors seen in this disorder.
C. Display of self-harming behaviors such as head-banging
Self-injurious behaviors, including head-banging or biting, can occur in children with ASD, especially when they experience frustration, anxiety, or sensory overload. Recognizing these behaviors helps guide intervention and safety measures.
E. Adhering to a rigid routine
Children with ASD typically prefer predictable routines and may become distressed by changes. This need for consistency supports their coping and sense of security.
A nurse is teaching a client about tetanus. Which of the following statements should the nurse make? (Select all that apply.)
A. “A deep wound that has come in contact with soil, dirt, or dust could become infected with tetanus.”
Tetanus is caused by Clostridium tetani, an anaerobic, spore-forming bacterium that thrives in environments low in oxygen. The spores are commonly found in soil and dust. Deep puncture wounds, lacerations, or burns provide an ideal anaerobic environment for the spores to germinate and produce tetanospasmin, the neurotoxin responsible for muscle rigidity and spasms. This emphasizes the need for prompt wound cleaning and assessment of vaccination status.
C. “Wounds that come in contact with contaminated animal feces can cause tetanus.”
Animal feces, particularly from farm animals like cattle, horses, and pigs, can contain C. tetani spores. Wounds exposed to feces, manure, or contaminated soil are at significant risk for infection. This is clinically relevant in children who play outdoors or in agricultural settings and underscores the importance of thorough cleansing and prophylactic vaccination.
D. “Newborns are at risk if their parent is unvaccinated or gives birth in unsanitary conditions.”
Neonatal tetanus occurs when spores enter through the umbilical cord stump or contaminated birth instruments. The risk is highest when mothers are unvaccinated and hygienic birth practices are not followed. The disease can be fatal due to generalized muscle rigidity, including respiratory muscles, highlighting the importance of maternal vaccination (Tdap) and sterile delivery techniques.
E. “Since there is no treatment for tetanus once acquired, vaccination is very important.”
Tetanus is a toxin-mediated disease with no definitive cure; management is supportive, including muscle relaxants, airway support, and wound debridement, but recovery depends on the body neutralizing the toxin. Vaccination is the most effective preventive measure, typically using the DTaP series in children, with booster Tdap vaccines in adolescents and adults. Educating clients about vaccination schedules ensures long-term immunity and prevention of severe disease outcomes.
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