Nokea
A client has undergone a mastectomy. The nurse determines that the client is having the most difficulty adjusting to the loss of the breast when which behavior is observed?
- A. Refuses to look at the dressing
- B. Requires help with sponge bathing
- C. Asks that the nurse limit visitors to only family
- D. Dresses in a loose nightgown the client brought from home
Correct Answer: A
Rationale: The client demonstrates the most difficult adjustment to the loss if she refuses to look at the dressing. This indicates that the client is not ready or willing to begin to acknowledge and cope with the surgery. Requiring help with sponge bathing is expected after major surgery, limiting visitors is also an expected behavior soon after surgery, and dressing in her own nightgown indicates that the client is retaining her self-esteem.
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A client has undergone a vasectomy. The nurse instructs the client that he can begin having unprotected intercourse:
- A. When desired because sterilization is immediate.
- B. As soon as scrotal edema and tenderness resolve.
- C. When the sperm count reflects sterilization.
- D. After 6 to 10 ejaculations.
Correct Answer: C
Rationale: A vasectomy requires confirmation of azoospermia (no sperm in semen) via sperm count before unprotected intercourse to ensure sterilization, as sperm may remain in the reproductive tract initially.
Which of the following demonstrates that the client needs further instruction after being taught about ciprofloxacin (Cipro)?
- A. I must drink 1,000 to 1,500mL of water a day
- B. I shouldn't take an antacid before taking the Cipro
- C. I should let the doctor know if I start vomiting from the Cipro
- D. I may get light-headed from the Cipro
Correct Answer: A
Rationale: Adequate hydration is important with ciprofloxacin, but 1,000–1,500 mL may be insufficient for adults, who typically need 2,000–3,000 mL daily to prevent crystalluria. Other statements are correct.
The nurse caring for a client who recently received an epidural anesthesia for a vaginal delivery suspects the presence of a vaginal hematoma. Which finding would be the best indicator of the presence of this type of hematoma?
- A. Changes in vital signs
- B. Signs of vaginal bruising
- C. Client reporting a tearing sensation
- D. Client reporting intense vaginal pressure
Correct Answer: A
Rationale: Changes in vital signs indicate hypovolemia in the anesthetized postpartum woman with a vaginal hematoma. Vaginal bruising may be present, but this may be a result of the delivery process and additionally is not the best indicator of the presence of a hematoma. Because the client received anesthesia, she would not feel pain or pressure.
A client with a history of epilepsy is prescribed carbamazepine (Tegretol). Which side effect should the nurse teach the client to report?
- A. Drowsiness
- B. Nausea
- C. Rash
- D. Dry mouth
Correct Answer: C
Rationale: A rash may indicate a serious hypersensitivity reaction to carbamazepine, such as Stevens-Johnson syndrome, requiring immediate reporting.
The nurse is assessing a client with suspected pulmonary edema. Which finding is most indicative?
- A. Dry cough.
- B. Crackles at lung bases.
- C. Clear breath sounds.
- D. Decreased respiratory rate.
Correct Answer: B
Rationale: Crackles at lung bases indicate fluid in the alveoli, a hallmark of pulmonary edema.