Nokea
A 38-year-old woman, mother of two, has a mastectomy for breast cancer.
- A. Which client response one month after a mastectomy indicates a normal reaction to the surgery?
- B. I have been helping my family deal with their feelings about the surgery.'
- C. I have been having difficulty coping with the surgery and cry frequently.'
- D. I have been unable to leave the house or talk to my friends about the surgery.'
- E. I am doing just great since the surgery and have gone back to work at my job.'
Correct Answer: B
Rationale: Frequent crying and difficulty coping one month post-mastectomy reflect a normal grieving process for the loss of a body part. Helping family cope is premature, social withdrawal indicates abnormal adjustment, and immediate return to normal activities suggests denial, which is too early for integration.
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The nurse is caring for a client with a sigmoid colostomy who requests assistance in removing the flatus from a 1 piece drainable ostomy pouch. Which is the correct intervention?
- A. Piercing the plastic of the ostomy pouch with a pin to vent the flatus
- B. Opening the bottom of the pouch, allowing the flatus to be expelled
- C. Pulling the adhesive seal around the ostomy pouch to allow the flatus to escape
- D. Assisting the client to ambulate to reduce the flatus in the pouch
Correct Answer: B
Rationale: Opening the bottom of the pouch, allowing the flatus to be expelled, is the correct way to vent a 1-piece drainable ostomy pouch.
A client on suicide precautions is verbalizing other options besides suicide, appears to be responding to antidepressant medication, is sleeping and eating better, and has indicated a willingness to interact more with family members.
Based on this data, which of the following nursing actions is MOST appropriate?
- A. Recommend that the physician decrease the client's medication dosage.
- B. Recommend that the treatment team reevaluate the client's treatment plan.
- C. Give the client privileges to walk around the hospital by himself.
- D. Ask the family to begin planning for the client's discharge.
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) may reverse the client's progress (2) correct-data suggests that client is beginning to benefit from treatment; entire treatment team should share data and make a decision about the suicide precautions so that restrictions are changed gradually based on a full-data picture (3) may be the team's decision, but not until a thorough review of the case is completed (4) premature
A 32-year-old multipara is seen in the prenatal clinic. The nurse notes she is in her fifth month of pregnancy and has a weight gain of 14 pounds. The history indicates that prenatally the client was of average height and weight.
The nurse should advise the client that
- A. she has gained too much weight and her diet should be reevaluated.
- B. she has not gained enough weight and her diet should be reevaluated.
- C. her weight gain is appropriate and she should continue on her present diet.
- D. her weight gain indicates that she may have difficulties later in pregnancy.
Correct Answer: C
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) excessive weight gain is >6.6 lb (3 kg)/month (2) inadequate weight gain is <2.2 lb (1 kg)/month (3) correct-weight gain 2-5 lb (2.5 kg) first trimester, 0.66-1.1 lb (0.5 kg) weekly in second and third trimester (4) not substantiated by information presented in question
An arthritic client must be able to perform tasks to manage at home alone following discharge from the hospital.
The nurse knows that to manage at home alone following discharge from the hospital, an arthritic client must be able to perform which of the following tasks?
- A. Climb up and down stairs.
- B. Lace and tie his/her shoes.
- C. Comb his/her hair and brush his/her teeth.
- D. Walk without assistance.
Correct Answer: C
Rationale: Strategy: Think about the significance of each answer choice and how it relates to arthritis. (1) stairs can be eliminated in the client's environment (2) is a modifiable problem with the use of slip-on shoes (3) correct-is part of basic hygiene and grooming that must be done daily to maintain overall health (4) is not necessary for independence; walker or wheelchair may be used
When obtaining a specimen from a client for sputum culture and sensitivity (C and S), the nurse knows that which of the following instructions is BEST?
- A. After pursed-lip breathing, cough into a container.
- B. Upon awakening, cough deeply and expectorate into a container.
- C. Save all sputum for three days in a covered container.
- D. After respiratory treatment, expectorate into a container.
Correct Answer: B
Rationale: specimens should be obtained in the early morning because secretions develop during the night