A 72-year-old male client had the Foley catheter removed today, which was inserted during the transurethral resection of the prostate (TURP). The client is concerned about the urinary incontinence he has experienced since removal of the Foley catheter. The nurse should explain to the client that:
- A. he should not be concerned, because it will be quickly resolved.
- B. urinary incontinence is usually temporary.
- C. he should notify the nurse when this happens.
- D. this is related to the bladder spasms and will soon stop.
Correct Answer: B
Rationale: Urinary incontinence is usually temporary, but the problem may take some time to resolve, especially in an older male. Bladder spasms are not the cause of the client's incontinence.
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Which assessment finding signals the most serious and life-threatening condition?
- A. A deviated trachea
- B. Gross deformity in a lower extremity
- C. Decreased breath sounds
- D. Hemoptysis
Correct Answer: A
Rationale: A deviated trachea indicates possible tension pneumothorax, a life-threatening condition.
The nurse is caring for a client with trigeminal neuralgia. To assist the client with nutrition needs, the nurse should:
- A. Offer small meals of high calorie soft food.
- B. Assist the client to sit in a chair for meals.
- C. Provide additional servings of fruits and raw vegetables.
- D. Encourage the client to eat fish, liver and chicken.
Correct Answer: A
Rationale: Soft foods minimize facial muscle movement, reducing pain.
When working as a professional nurse, what is the priority for a new nurse working on an inpatient medical-surgical unit with a preceptor?
- A. Attending to holistic client needs
- B. Ensuring client safety
- C. Avoiding medication errors
- D. Providing client-focused care
Correct Answer: B
Rationale: The correct answer is B: Ensuring client safety. This is the priority for a new nurse working on an inpatient medical-surgical unit with a preceptor because safety is the foundation of nursing care. Ensuring client safety involves preventing harm, maintaining a safe environment, and implementing appropriate interventions. Attending to holistic client needs (A) and providing client-focused care (D) are important aspects of nursing practice but ensuring client safety takes precedence. Avoiding medication errors (C) is crucial for patient safety but is just one aspect of ensuring overall client safety.
What is the term used for assessment data that the patient tells you about?
- A. Focused
- B. Objective
- C. Subjective
- D. Comprehensive
Correct Answer: C
Rationale: The correct answer is 'Subjective.' Subjective data includes patient-reported symptoms, feelings, and experiences.
A healthcare professional is assessing a client with rheumatoid arthritis. Which assessment finding is most characteristic of this disease?
- A. Asymmetrical joint involvement
- B. Heberden's nodes
- C. Morning stiffness lasting more than 30 minutes
- D. Pain that worsens with activity
Correct Answer: C
Rationale: The correct answer is C: Morning stiffness lasting more than 30 minutes. This is characteristic of rheumatoid arthritis due to the inflammatory nature of the disease. The prolonged morning stiffness is a hallmark feature, reflecting the systemic inflammation present in rheumatoid arthritis. This symptom is not typically seen in osteoarthritis, which rules out options A and B. Pain that worsens with activity is more indicative of osteoarthritis as opposed to rheumatoid arthritis, making option D incorrect.