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A 32-year-old female meets with the nurse on her first office visit since undergoing a left mastectomy. When asked how she is doing, the woman says her appetite is still not good, she is not getting much sleep because she doesn't go to bed until her husband is asleep, and she is really anxious to get back to work. Which of the following nursing interventions should the nurse explore to support the client's current needs?
- A. Call the physician to discuss allowing the client to return to work earlier.
- B. Suggest that the client learn relaxation techniques for help with her insomnia.
- C. Perform a nutritional assessment to assess for anorexia.
- D. Ask open-ended questions about sexuality issues related to her mastectomy.
Correct Answer: B
Rationale: Insomnia is a primary concern, and relaxation techniques can help improve sleep, addressing the client's emotional and physical recovery needs post-mastectomy.
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A 60-year-old female is diagnosed with hypothyroidism. The nurse should assess the client for which of the following?
- A. Tachycardia.
- B. Weight gain.
- C. Diarrhea.
- D. Nausea.
Correct Answer: B
Rationale: Hypothyroidism causes a slowed metabolism, leading to weight gain. Tachycardia, diarrhea, and nausea are more associated with hyperthyroidism.
For breakfast on the morning a client is to have an electroencephalogram (EEG), the client is served a soft-boiled egg, toast with butter and marmalade, orange juice, and coffee. Which of the following should the nurse do?
- A. Remove all the food.
- B. Remove the coffee.
- C. Remove the toast, butter, and marmalade only.
- D. Substitute vegetable juice for the orange juice.
Correct Answer: B
Rationale: Coffee should be removed because caffeine can alter brain wave activity, affecting EEG results. The other foods do not typically interfere with the test.
Which client position is contraindicated for a client with a spinal cord injury?
- A. Supine with head flat.
- B. Logrolling technique.
- C. Head elevated 30 degrees.
- D. Neutral neck alignment.
Correct Answer: A
Rationale: Supine with head flat is contraindicated as it may increase spinal pressure; other positions support alignment and safety.
A client undergoes surgery to repair lung injuries. Postoperative orders include the transfusion of one unit of packed red blood cells at a rate of 60 mL/hour. How long would this transfusion take to infuse?
- A. 2 hours.
- B. 4 hours.
- C. 6 hours.
- D. 8 hours.
Correct Answer: B
Rationale: A unit of packed red blood cells is approximately 250–300 mL. At 60 mL/hour, 240 mL (close to a unit) takes 240 ÷ 60 = 4 hours.
The nurse is assessing the lower extremities of the client with peripheral vascular disease (PVD). During the assessment, the nurse should expect to find which of the following clinical manifestations of PVD?
- A. Hairy legs
- B. Mottled skin
- C. Pink, cool skin
- D. Warm, moist skin
Correct Answer: B
Rationale: Mottled skin (livedo reticularis) is a common manifestation of PVD due to poor perfusion, causing irregular skin discoloration. Hairy legs, pink cool skin, or warm moist skin are not typical; PVD often presents with hair loss, cool, pale, or cyanotic skin.