Nokea
The nurse is teaching a group of college students about breast self-examination. A woman asks for the best time to perform the monthly exam. What is the best reply by the nurse?
- A. The first of every month, because it is easiest to remember'
- B. Right after the period, when your breasts are less tender'
- C. Do the exam at the same time every month'
- D. Ovulation, or mid-cycle is the best time to detect changes'
Correct Answer: B
Rationale: The best time for a breast self-exam (BSE) is a week after a menstrual cycle, when the breasts are no longer swollen and tender due to hormone elevation.
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To obtain this nutrient, the nurse should tell pregnant clients to eat:
- A. Celery
- B. Bananas
- C. Cooked beef liver
- D. Boiled turkey breast
Correct Answer: C
Rationale: Cooked beef liver is rich in folic acid, essential for preventing neural tube defects.
When a patient is unconscious, the nurse should expect the patient to be unable to:
- A. Hear voices.
- B. Control elimination.
- C. Move spontaneously.
- D. React to painful stimuli.
Correct Answer: B
Rationale: Unconscious patients cannot control elimination due to loss of voluntary muscle control.
A 40-year-old woman is admitted in labor with high blood pressure, edema, and proteinuria. She is started on magnesium sulfate. The nurse caring for her should be sure to keep which drug at the bedside?
- A. Calcium gluconate
- B. Naloxone (Narcan)
- C. Phenytoin (Dilantin)
- D. Glucose
Correct Answer: A
Rationale: Magnesium sulfate, used for preeclampsia, can cause toxicity; calcium gluconate is the antidote, reversing respiratory depression or cardiac effects, and must be readily available.
The nurse should
- A. Give her 15 milliliters of ipecac syrup and a large glass of water
- B. Prepare her for gastric lavage
- C. Catheterize her for a fresh urine sample
- D. Start an intravenous infusion for administration of an antidote
Correct Answer: B
Rationale: Gastric lavage is the priority to remove aspirin from the stomach, preventing further absorption.
A client comes to the emergency department complaining of headache, malaise, chills, fever, and a stiff neck. Vital sign assessment reveals a temperature elevation, increased heart and respiratory rates, and normal blood pressure. On physical examination, the nurse notes confusion, a petechial rash, nuchal rigidity, Brudzinski's sign, and Kernig's sign. What does Brudzinski's sign indicate?
- A. Increased intracranial pressure (ICP)
- B. Cerebral edema
- C. Low cerebrospinal fluid (CSF) pressure
- D. Meningeal irritation
Correct Answer: D
Rationale: Brudzinski's sign indicates meningeal irritation, as in meningitis. Other signs of meningeal irritation include nuchal rigidity and Kernig's sign. Brudzinski's sign doesn't indicate increased ICP, cerebral edema, or low CSF pressure.