Nokea
A client has a history of fibrocystic disorder of the breasts. The nurse determines that the client understands the nature of the disorder when the client states that symptoms are most likely to occur at which time?
- A. After menses
- B. Before menses
- C. In the spring months
- D. In the winter months
Correct Answer: B
Rationale: Fibrocystic breast disorder is characterized by cyclical breast pain and tenderness due to hormonal fluctuations, with symptoms most pronounced before menses when estrogen levels peak, leading to breast tissue swelling and cyst formation. Symptoms typically subside after menses. Seasonal changes, such as spring or winter months, do not influence fibrocystic breast symptoms.
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A client demonstrating unstable ventricular tachycardia (VT) loses consciousness and becomes pulseless after an initial treatment with a dose of lidocaine intravenously. Which item should the nurse caring for the client immediately obtain?
- A. A pacemaker
- B. A defibrillator
- C. A second dose of lidocaine
- D. An electrocardiogram machine
Correct Answer: B
Rationale: For the client with VT who becomes pulseless, the primary health care provider or qualified advanced cardiac life support personnel immediately defibrillate the client. In the absence of this equipment, cardiopulmonary resuscitation is initiated immediately. None of the remaining options are items that are needed immediately to manage this situation.
The nurse is talking with a client who was diagnosed with bulimia 3 months ago. The client needs more education about the illness if she makes which of the following comments? Select all that apply.
- A. I know that this illness is chronic and intermittent. I'll always have to control it
- B. If I start severely restricting my eating, I may be building up to a bingeing episode
- C. When I'm not bingeing and purging, I can skip that Eating Disorder support group
- D. I've made a real effort to be more social and involved in activities
- E. My depression is gone so I don't need my antidepressant any longer
Correct Answer: C,E
Rationale: Skipping support groups during non-bingeing periods and stopping antidepressants due to improved mood indicate a need for further education, as bulimia requires ongoing support and medication adherence. Other statements reflect accurate understanding.
The nurse is caring for a client with a history of diverticulitis. Which of the following foods should the nurse recommend during the acute phase?
- A. Clear liquids.
- B. High-fiber foods.
- C. Red meat.
- D. Whole grains.
Correct Answer: A
Rationale: Clear liquids reduce bowel irritation during acute diverticulitis.
You are serving as the preceptor for a newly graduated nurse. As you observe the new nurse for their application of body mechanics principles into client care, you observe that the nurse spreads her legs apart during a transfer with a client. What should you do?
- A. Advise the nurse that the legs must be close together for stability during lifting and transfers.
- B. Advise the nurse that the legs should be one in front of the other and not spread apart during a transfer.
- C. Validate the nurse's competency in terms of the application of body mechanics principles during a transfer.
- D. Validate the nurse's competency in terms of the application of ergonomics principles during a transfer.
Correct Answer: C
Rationale: Spreading the legs apart during a transfer provides a wide base of support, which is a correct body mechanics principle , ensuring stability and reducing injury risk.
The nurse evaluates the arterial blood gas (ABG) results of a client who is receiving supplemental oxygen. Which Po2 finding would indicate that the oxygen level was adequate?
- A. 45 mm Hg
- B. 50 mm Hg
- C. 60 mm Hg
- D. 80 mm Hg
Correct Answer: D
Rationale: The normal Po2 level is 80 to 100 mm Hg. The remaining options are low values and do not indicate adequate oxygen levels.