Nokea
A client is being prepared to have a craniotomy for a brain tumor. As a client advocate, the nurse is evaluating the client's understanding of the informed consent before witnessing the client's signature on the operative consent form. Which of the following indicates that the nurse needs to contact the surgeon for further communication with the client?
- A. We talked about the effect of my diabetes on healing.'
- B. œThe surgeon explained how the craniotomy was done.'
- C. œThere are no major risks from this surgery.'
- D. œI will die if the tumor is not removed from my brain.'
Correct Answer: C
Rationale: Stating there are no major risks indicates a misunderstanding, as craniotomy carries significant risks (e.g., bleeding, infection). The nurse must contact the surgeon to clarify risks for informed consent.
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Which of the following guidelines reflects the current American Cancer Society recommendations for screening for colon cancer in individuals who are not at high risk?
- A. Annual digital rectal examination should begin at age 40.
- B. Annual fecal testing for occult blood should begin at age 50.
- C. Individuals should obtain a baseline barium enema at age 40.
- D. Individuals should obtain a baseline colonoscopy at age 45.
Correct Answer: B
Rationale: Annual fecal testing for occult blood should begin at age 50. Annual digital rectal examinations are recommended in men beginning at age 50 to screen for prostate cancer. Baseline barium enemas or colonoscopies are recommended at age 50. Baseline barium enemas and colonoscopies are not performed on individuals in their 40s unless they recommend the nurse to the need for such diagnostic testing, or are considered to be at high risk. CN: Health promotion and maintenance; CL: Apply
The client with a laryngectomy communicates to the nurse that he does not want his family to see him. He indicates that he thinks the opening in his throat is disgusting. Which of the following nursing diagnoses would be most appropriate?
- A. Deficient knowledge about the care of a stoma.
- B. Disturbed personal identity related to change in appearance.
- C. Disturbed body image related to neck surgery.
- D. Hopelessness related to irreversible changes in body functioning.
Correct Answer: C
Rationale: Disturbed body image related to neck surgery addresses the client's negative feelings about the stoma's appearance. Deficient knowledge is less relevant here. Disturbed personal identity is broader. Hopelessness implies a deeper psychological state not fully supported by the description.
The nurse is evaluating the discharge teaching for a client who has an ileal conduit. Which of the following statements indicates that the client has correctly understood the teaching? Select all that apply.
- A. If I limit my fluid intake, I will not have to empty my ostomy pouch as often.
- B. I can place an aspirin tablet in my pouch to decrease odor.
- C. I can usually keep my ostomy pouch on for 3 to 7 days before changing it.
- D. I must use a skin barrier to protect my skin from urine.
- E. I should supply my ostomy pouch of urine when it is full.
Correct Answer: C,D
Rationale: Keeping the pouch on for 3-7 days and using a skin barrier are correct practices. Limiting fluids increases infection risk, aspirin is unsafe, and the last option is unclear but likely a typo for emptying when full, which is correct but not listed as such.
To prepare the irrigation solution used for removal of cerumen, the nurse should use:
- A. Normal saline.
- B. Sterile water.
- C. Antiseptic solution.
- D. Warm tap water.
Correct Answer: A
Rationale: Normal saline is the preferred solution for ear irrigation, as it is isotonic and safe for the ear canal, minimizing irritation or risk of infection.
The physician orders Morphine Sulfate 2-4 mg IV push every 2 hours prn pain for a client who has postoperative pain following abdominal surgery. Prior to performing an abdominal dressing change with packing at 10 AM, the nurse assesses the client's pain level as 1 on a scale of 0 = no pain to 10 = the worst pain. The client is awake and oriented and vital signs are within normal limits. The nurse reviews the pain medication record (see chart). The nurse should:
- A. Perform the dressing change.
- B. Administer Morphine 2 mg IV before the dressing change.
- C. Administer Morphine 4 mg IV after the dressing change.
- D. Call the physician for a new medication order.
Correct Answer: A
Rationale: With a pain level of 1, the client does not require morphine (prn order). Performing the dressing change is appropriate, as the pain is minimal and manageable.