a nurse is caring for a client who has a pharyngeal diphtheriwhich of the following types of transmission precautions should the nurse initiate
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1. A client has pharyngeal diphtheria. Which of the following types of transmission precautions should the nurse initiate?

Correct answer: A

Rationale: Pharyngeal diphtheria is transmitted via droplets, primarily through respiratory secretions. Therefore, droplet precautions are necessary to prevent the spread of the infection. Droplet precautions involve wearing a surgical mask, goggles, and a gown when within three feet of the client. Contact precautions are used for diseases transmitted by direct or indirect contact; airborne precautions are for diseases transmitted through airborne particles; protective precautions are not a standard precaution type.

2. A staff nurse is teaching a newly hired nurse about alternatives to the use of restraints on clients who are confused. Which of the following instructions should the nurse include?

Correct answer: C

Rationale: Encouraging physical activity is an effective non-restraint intervention for managing confused clients. It helps reduce agitation, promotes circulation, and may decrease the need for restraints. Choice A is incorrect as using full-length side rails can potentially restrict a client's movement, which is counterproductive to avoiding restraints. Choice B, while emphasizing monitoring, does not directly address alternatives to restraint use. Choice D is also incorrect as removing clocks from the client's room does not directly address managing confusion and reducing the need for restraints.

3. The nurse is teaching the parents of a child who has head lice (pediculosis capitis). Which information will the nurse include in the teaching session?

Correct answer: C

Rationale: The correct answer is C. Head lice are highly contagious and can spread to furniture and other people if not treated promptly. Informing the parents about the potential spread of head lice emphasizes the importance of thorough treatment and prevention measures. Choice A is incorrect as regular shampoo is not typically effective in treating head lice. Choice B is incorrect as products containing lindane are not recommended due to safety concerns. Choice D is incorrect as manual removal, though labor-intensive, is a crucial step in effectively treating head lice infestations, but it is not the most pertinent information to include in the teaching session.

4. During the check-up of a 2-month-old infant at a well-baby clinic, the mother expresses concern to the nurse because a flat pink birthmark on the baby's forehead and eyelid has not gone away. What is an appropriate response by the nurse?

Correct answer: C

Rationale: The correct answer is C. Telangiectatic nevi, often referred to as 'stork bites,' are common birthmarks in infants and are considered normal. These birthmarks usually fade and disappear as the child grows older. Choices A, B, and D are incorrect because Mongolian spots are bluish-gray birthmarks commonly found in darker-skinned infants, port wine stains are vascular birthmarks that typically do not disappear, and surgical removal is not recommended for telangiectatic nevi as they usually resolve on their own.

5. A client expresses that, based on religious values and mandates, a blood transfusion is not an acceptable treatment option. Which of the following responses should the nurse make?

Correct answer: D

Rationale: The correct response is to involve the client's religious and spiritual leaders in the discussion to find a solution that respects both the client's values and medical needs. Option A is incorrect as it dismisses the client's beliefs. Option B assumes the family's opinion over the client's. Option C is inappropriate as it questions the client's religious beliefs rather than addressing the concern respectfully.

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