Nokea
A nurse is reinforcing teaching with a 40-year-old female client about preventive health screenings. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should have my skin checked every 5 years for cancer.
- B. I will need to have a mammogram every year now.
- C. I should have my first colonoscopy when I turn 65.
- D. I will be checked for uterine cancer every 2 years.
Correct Answer: B
Rationale: The correct answer is B: "I will need to have a mammogram every year now." This statement indicates an understanding of preventive health screenings for a 40-year-old female. Mammograms are recommended annually starting at age 40 to screen for breast cancer. Choice A is incorrect as skin checks for cancer should be more frequent than every 5 years. Choice C is incorrect as the first colonoscopy is recommended at age 50, not 65. Choice D is incorrect as uterine cancer screening is typically not done every 2 years.
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A nurse is caring for an older adult client who has constipation. Which of the following actions should the nurse take?
- A. Request that the provider prescribe a stool softener.
- B. Promote active range-of-motion activities.
- C. Add fluid and fiber to the diet.
- D. Avoid gas-producing foods.
Correct Answer: C
Rationale: The correct answer is C: Add fluid and fiber to the diet. Increasing fluid intake helps soften the stool, making it easier to pass. Fiber adds bulk to the stool, promoting regular bowel movements. This is a non-invasive and effective intervention for constipation in older adults. Requesting a stool softener (A) may be considered if dietary interventions are ineffective. Promoting active range-of-motion activities (B) may help prevent constipation but is not the first-line intervention. Avoiding gas-producing foods (D) is not directly related to treating constipation.
A nurse whose left hand is dominant is preparing to perform a straight catheterization for a client who is paraplegic. Which of the following actions should the nurse take?
- A. Use the left hand to cleanse the urinary meatus.
- B. Use the right hand to insert the catheter.
- C. Stand on the client's right side.
- D. Raise the bed to a comfortable working height.
Correct Answer: D
Rationale: The correct answer is D: Raise the bed to a comfortable working height. This is important to prevent strain on the nurse's back and ensure proper ergonomics during the procedure. Standing on the client's right side (Choice C) does not directly impact the procedure. Using the left hand to cleanse the urinary meatus (Choice A) could be challenging for a left-handed nurse and may not be as efficient. Using the right hand to insert the catheter (Choice B) could also be difficult for a left-handed nurse and may affect dexterity. Therefore, raising the bed to a comfortable working height is the most appropriate action to ensure the nurse's comfort and safety while performing the catheterization.
A nurse is collecting data from a client who has narcolepsy. Which of the following manifestations should the nurse expect? (Select all that apply).
- A. Feeling extremely tired upon waking
- B. Sudden attacks of sleep
- C. Sleep-wake cycle hallucinations
- D. Sleep apnea
- E. Urge to move the legs when trying to sleep
Correct Answer: B, C
Rationale: The correct manifestations for narcolepsy are sudden attacks of sleep and sleep-wake cycle hallucinations. Narcolepsy is a neurological disorder characterized by excessive daytime sleepiness, sudden attacks of sleep (choice B), and disrupted REM sleep leading to sleep-wake cycle hallucinations (choice C). Choice A (feeling extremely tired upon waking) is more indicative of general fatigue rather than narcolepsy. Choice D (sleep apnea) is a separate sleep disorder characterized by pauses in breathing during sleep. Choice E (urge to move the legs when trying to sleep) is a symptom of restless leg syndrome, which is not typically associated with narcolepsy.
A nurse at a community-based health fair is promoting having a routine Papanicolaou test (Pap smear) to young adult women. Which of the following types of preventive care is the Pap smear?
- A. Primary level
- B. Secondary level
- C. Tertiary level
- D. Self-care ability level.
Correct Answer: B
Rationale: The correct answer is B: Secondary level preventive care. A Pap smear is a screening test that aims to detect precancerous or cancerous cells in the cervix at an early stage. This type of preventive care falls under secondary prevention because it focuses on early detection and treatment of disease before it progresses. Primary prevention (choice A) aims to prevent the disease from occurring in the first place. Tertiary prevention (choice C) focuses on managing and reducing the impact of the disease after it has already developed. Self-care ability level (choice D) is not a recognized level of preventive care.
A nurse is observing a client's nonverbal behavior. When evaluating this behavior, the nurse should factor in which of the following principles that influence nonverbal communication?
- A. Nonverbal communication conveys less truth than what the client states verbally.
- B. The client's sociocultural background influences nonverbal communication.
- C. Nonverbal communication is a poor reflection of what the client feels.
- D. The client enacts nonverbal communication consciously.
Correct Answer: B
Rationale: The correct answer is B: The client's sociocultural background influences nonverbal communication. Nonverbal communication is greatly impacted by an individual's cultural norms, values, and beliefs. This influences gestures, facial expressions, posture, and personal space preferences. Understanding the client's sociocultural background helps the nurse interpret nonverbal cues accurately.
Choice A is incorrect because nonverbal communication can often convey more truth than verbal statements as it can be more spontaneous and genuine. Choice C is incorrect because nonverbal behavior can provide valuable insights into a client's true feelings and emotions. Choice D is incorrect because nonverbal communication is often unconscious and can be influenced by subconscious factors.