Nokea
The nurse is talking with a group of parents about puberty. The nurse should include that the first sign of puberty in clients of the male sex is
- A. increased height
- B. greater muscle mass
- C. testicular enlargement
- D. increased length of the penis
Correct Answer: C
Rationale: Testicular enlargement (C) is the first sign of puberty in males, occurring before height increase (A), muscle mass gain (B), or penile growth (D).
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The nurse monitoring a client with appendicitis will expect the client to give which description of the associated abdominal pain?
- A. A burning sensation; in the upper abdomen
- B. An 8 out of 10; on the left side below the belly button
- C. Excruciating; in the lower abdomen above the right hip
- D. Intermittent; in the abdomen and right shoulder
Correct Answer: C
Rationale: Appendicitis typically causes severe pain in the right lower quadrant (C). Upper abdominal burning (A) suggests gastritis, left-sided pain (B) is atypical, and shoulder pain (D) may indicate referred pain from other conditions.
The nurse is caring for a client who had a forceps-assisted vaginal birth and is reporting severe vaginal pain and fullness. The nurse notes the fundus is firm and midline with a scant amount of lochia rubra. The client is most likely experiencing
- A. uterine atony
- B. vaginal hematoma
- C. cervical lacerations
- D. inversion of the uterus
Correct Answer: B
Rationale: Severe vaginal pain and fullness with a firm fundus and scant lochia suggest a vaginal hematoma (B). Uterine atony (A) causes heavy bleeding, cervical lacerations (C) cause bleeding, and uterine inversion (D) involves a displaced fundus.
Which procedures are appropriate for the nurse to use when obtaining an adult client's blood for a laboratory test? Select all that apply.
- A. Avoid the arm on the affected side after a mastectomy
- B. Do not make further attempts to draw blood if unsuccessful on first 2 attempts
- C. If necessary to use an arm with IV infusing, draw proximal to infusion point
- D. Insert the needle bevel up at a 15-degree angle to the skin
- E. Obtain a finger capillary specimen from the middle of the finger pad
Correct Answer: A,B,C
Rationale: Avoiding the mastectomy side (A), limiting attempts to two (B), and drawing proximal to an IV (C) are correct. A 15-degree angle (D) is for IVs, not phlebotomy, and capillary samples avoid the finger pad center (E).
A 62-year-old client admitted to the telemetry unit after an acute myocardial infarction 3 days ago reports that the left calf is very tender and warm to the touch. Which nursing intervention is the priority?
- A. Asking the client how long the leg has been tender and warm
- B. Checking the electrocardiogram for ectopic beats
- C. Obtaining vital signs, including pulse oximetry
- D. Performing a neurovascular check on the lower extremities
Correct Answer: D
Rationale: Tenderness and warmth suggest deep vein thrombosis, so a neurovascular check (D) is the priority to assess for complications. History (A), ECG (B), and vitals (C) are secondary.
The nurse is caring for a client with syndrome of inappropriate antidiuretic hormone. Which of the following actions should the nurse take? Select all that apply.
- A. Administer vasopressin.
- B. Implement seizure precautions.
- C. Perform frequent neurological checks.
- D. Keep a strict record of fluid intake and output.
- E. Maintain an IV infusion of 0.9% sodium chloride.
Correct Answer: B,C,D
Rationale: Seizure precautions (B), neurological checks (C), and strict I&O (D) manage SIADH complications like hyponatremia. Vasopressin (A) worsens SIADH, and normal saline (E) may not correct hyponatremia.