A client states, 'I eat a well-balanced diet. I do not smoke. I exercise regularly, and I have a yearly checkup with my physician. What else can I do to help prevent cancer?' The nurse should respond with which of the following statements?
- A. Sleep at least 6-8 hours a night
- B. Practice monthly self-breast examination
- C. Reduce stress
- D. All of the above
Correct Answer: D
Rationale: All listed actions contribute to cancer prevention: adequate sleep supports immune function, self-breast exams aid early detection, and stress reduction enhances overall health. These complement the client's existing healthy habits.
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A newborn baby exhibits a reflex that includes: hand opening, abducted and extended extremities following a jarring motion. Which of the following correctly identifies the reflex?
- A. ATNR reflex
- B. Startle reflex
- C. Grasping reflex
- D. Moro reflex
Correct Answer: D
Rationale: The moro reflex has all of the listed characteristics.
A nurse witnesses a client sign the consent form for surgery with the surgeon. As the surgeon leaves, the client starts to speak and then stops. The nurse asks if the client has further questions and he says, 'I don't want to bother the surgeon.' The nurse should
- A. acknowledge the client's wish not to bother the surgeon and tell the client to let you know if they change their mind
- B. acknowledge the client's wish not to bother the surgeon and answer all of their questions, as appropriate
- C. go get the surgeon to answer all of the client's questions
- D. answer any questions as appropriate as well as have the surgeon come back to answer any questions if needed
Correct Answer: D
Rationale: Nurses should always advocate for their clients, making sure they understand everything involving their health as well as ensuring all questions are answered appropriately and thoroughly.
A legal right to confidentiality of client information is waived when:
- A. a court system subpoenas information.
- B. a family member requests health care information of a client.
- C. a living will takes effect.
- D. the client is declared incompetent by the legal system.
Correct Answer: A
Rationale: The legal right to confidentiality is waived when the court requires information for legal proceedings, when the state requires mandatory reporting, when a client reveals intent to harm, or when a client cannot make safe decisions.
An advance directive is written and notarized according to law in the state of Colorado. This document is legal and binding:
- A. internationally.
- B. in the state of Colorado only.
- C. in the continental United States.
- D. in the county of origination only.
Correct Answer: B
Rationale: Advance directive protocols and documents are defined by each state.
A client being treated for sickle cell disease has an order for pain medication. Morphine was ordered, but the nurse is having difficulty deciphering the dose. The nurse should
- A. ask the attending physician to come back to the unit and to help read what the order states regarding the correct medication, dose, route, and frequency
- B. call the charge nurse to reach out to the attending physician to verify the order including the correct medication, dose, route, and frequency
- C. call the attending physician to verbally verify the order including correct medication, dose, route, and frequency
- D. just go with his or her gut on what the typical dose is for this medication and administer to the client so they do not have to wait on the physician
Correct Answer: C
Rationale: It is the nurse's responsibility to fully comprehend an attending physician's order prior to carrying it out. This includes verifying any confusing or indiscernible directions/orders via calling or discussing in person with the attending physician.