A nurse is caring for a client whose throat culture is positive for group A streptococcus 24 hours after a rapid strep test (RST) was negative. Which of the following actions is the nurse's priority?

Reinforce teaching about gargling with warm saline several times daily.

Ask the client to identify friends and family who have been in close contact.

Instruct the client to take antipyretics as directed for elevated temperature.

Notify the client to return to the clinic for initiation of antibiotic therapy.

Answer and Explanation

The Correct Answer is D

Choice A reason:
While gargling with warm saline can provide symptomatic relief for a sore throat, it does not address the underlying bacterial infection. Therefore, it is not the priority action once a diagnosis of group A streptococcus has been confirmed.

Choice B reason:
Identifying close contacts is important for public health tracking and potentially preventing the spread of the infection. However, the immediate priority for the client is the initiation of treatment to address the infection.

Choice C reason:
Taking antipyretics can help manage fever and provide comfort to the client. While managing symptoms is important, it is secondary to initiating antibiotic therapy, which addresses the cause of the symptoms.

Choice D reason:
The priority action is to notify the client to return to the clinic for initiation of antibiotic therapy. Group A streptococcus is a bacterial infection that requires antibiotics for treatment. Prompt initiation of antibiotics is crucial to prevent complications and promote recovery.

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Correct Answer is B

Explanation

Choice A reason:
While autoimmune disorders are associated with type 1 diabetes, where the immune system attacks the pancreas, they are not typically a direct risk factor for type 2 diabetes. Type 2 diabetes is more closely related to lifestyle factors and insulin resistance.

Choice B reason:
A 40-year-old client with hypoglycemia may be at risk for developing type 2 diabetes. Hypoglycemia can be a sign of pre-diabetes or insulin resistance, where the body's response to insulin is not as effective, leading to fluctuations in blood sugar levels. As individuals age, their risk for type 2 diabetes increases, particularly if they have other risk factors such as a sedentary lifestyle, overweight, or a family history of diabetes.

Choice C reason:
Lack of sleep can contribute to the development of type 2 diabetes by affecting the body's ability to regulate glucose and by increasing insulin resistance. However, without additional risk factors, it is not as strong a predictor of type 2 diabetes as the presence of hypoglycemia or other metabolic conditions.

Choice D reason:
Having never given birth is not a recognized risk factor for type 2 diabetes. While gestational diabetes is a risk factor for developing type 2 diabetes later in life, the absence of pregnancy does not increase the risk.

A. Who was the individual who assaulted you? B. What day and time did the assault take place? C. Where did the assault occur? D. Do you give us permission to call the police?

Correct Answer is B

Explanation

Choice A reason:
Asking about the identity of the assailant, while important for legal purposes, does not contribute to the immediate medical care of the client. The priority is to address potential health issues, such as exposure to HIV.

Choice B reason:
The timing of the assault is critical because it determines the eligibility for PEP. PEP should be initiated as soon as possible, ideally within 2 hours, but it can be effective up to 72 hours after exposure. Knowing the exact time of the assault helps healthcare providers act swiftly to mitigate the risk of HIV transmission.

Choice C reason:
While knowing where the assault occurred can provide context and may be relevant for legal proceedings, it does not influence the immediate medical treatment plan for potential HIV exposure.

Choice D reason:
Consent to involve law enforcement is a separate issue from medical treatment. While it's important to respect the client's wishes regarding reporting, it does not impact the decision-making process regarding HIV prophylaxis.

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A nurse is caring for a client whose throat culture is positive for group A streptococcus 24 hours after a rapid strep test (RST) was negative. Which of the following actions is the nurse's priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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