Nokea
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 per night.
- B. Practice monthly self-breast examinations.
- C. Reduce stress.
- D. All of the above.
Correct Answer: D
Rationale: All of the choices are methods of preventing cancer. Sleep is important in maintaining homeostasis, which helps the body respond to disease. Monthly breast examination can indicate cancer or fibrocystic disease. Stress can have a physiological response in the body that decreases the immune response and increases the risk of disease. Therefore, all the options provided are important in cancer prevention, making 'All of the above' the correct answer. Option A is crucial for overall health and immune function, option B aids in early detection, and option C is vital as chronic stress can weaken the immune system.
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A client with massive chest and head injuries is admitted to the ICU from the Emergency Department. All of the following are true except:
- A. The physician in charge of the case is the sole person allowed to decide whether organ donation can occur.
- B. The client's legally responsible party may make the decision for organ donation for the donor if the client is unable to do so.
- C. The organ procurement organization makes the decision regarding which organs to harvest.
- D. The donor (or legally responsible party for the donor), the physician, and the organ-procurement organization are all involved in the process.
Correct Answer: A
Rationale: While the physician plays a crucial role in the process of organ donation, they are not the sole decision-maker. The client's legally responsible party may make the decision for organ donation if the client is unable to do so. Additionally, the organ procurement organization is responsible for determining which organs are suitable for donation. Therefore, the statement that the physician in charge is the sole person allowed to decide whether organ donation can occur is incorrect. The correct answer is A. Choices B, C, and D are true statements as they highlight the involvement of the legally responsible party, the organ procurement organization, and the donor/legally responsible party, physician, and organ-procurement organization in the organ donation process respectively.
Ms. Petty is having difficulty falling asleep. Which of the following measures promote sleep?
- A. exercising vigorously for 20 minutes each night beginning at 9:30 p.m.
- B. taking a cool shower and drinking a hot cup of tea
- C. watching TV nightly until midnight
- D. getting a back rub and drinking a glass of warm milk
Correct Answer: D
Rationale: The correct answer is getting a back rub and drinking a glass of warm milk. These measures are relaxation techniques that can help promote sleep by calming the body and mind. Exercising vigorously right before bedtime, as mentioned in choice A, can increase arousal and make it harder to fall asleep. Choice B, taking a cool shower and drinking a hot cup of tea, involves temperature changes that might not be conducive to sleep. Watching TV until midnight, as in choice C, exposes the individual to blue light and mental stimulation, both of which can disrupt the natural sleep-wake cycle.
A 2-year-old child diagnosed with HIV comes to a clinic for immunizations. Which of the following vaccines should the nurse expect to administer in addition to the scheduled vaccines?
- A. pneumococcal vaccine
- B. hepatitis A vaccine
- C. Lyme disease vaccine
- D. typhoid vaccine
Correct Answer: A
Rationale: For a 2-year-old child diagnosed with HIV, in addition to the scheduled vaccines, the nurse should expect to administer the pneumococcal vaccine. Children with HIV are at an increased risk of infections, including pneumococcal disease. The pneumococcal vaccine helps protect against serious pneumococcal infections like pneumonia, meningitis, and bacteremia. The hepatitis A vaccine is not specifically recommended for all children with HIV unless there are specific risk factors. The Lyme disease vaccine is for individuals at risk for Lyme disease, typically between the ages of 15 and 70, transmitted by ticks. The typhoid vaccine is usually recommended for individuals traveling to endemic areas or working in specific high-risk occupations like microbiology laboratories dealing with Salmonella typhi.
Regarding maternal and infant mortality and morbidity, a concern is that:
- A. a segment of the population is not receiving prenatal care.
- B. families may not prioritize quality health care.
- C. there might be an increase in the shortage of personnel in the maternity field.
- D. maternal-child health workers may lack adequate preparation.
Correct Answer: A
Rationale: The correct answer is that a segment of the population is not receiving prenatal care. This is a significant concern as lack of access to prenatal care can lead to adverse outcomes for both the mother and the infant. Choice B is incorrect as it generalizes families as unconcerned, which may not be the case for all families. Choice C is also incorrect as there is no evidence or indication in the prompt to suggest an increase in the shortage of personnel. Choice D is not directly related to the concern mentioned in the prompt, which specifically focuses on the lack of prenatal care.
The teaching plan for a postpartum client who is about to be discharged should include which of the following instructions?
- A. "It is normal for your breasts to be tender. You should call the physician if you also have redness and fatigue."?
- B. "Because your baby was delivered vaginally, you might have to urinate more frequently."?
- C. "It is normal to run a low-grade temperature for a few days. If it is higher than 100°F, call your physician."?
- D. "Be sure to call your physician if your vaginal discharge becomes bright red."?
Correct Answer: D
Rationale: The correct answer is to instruct the postpartum client to call the physician if their vaginal discharge becomes bright red. The vaginal discharge after birth is called lochia, and a return to red or containing clots could indicate impending hemorrhage or infection, necessitating notification of the physician.
Choice A is incorrect because although some tenderness may be expected, redness and fatigue are clinical manifestations of mastitis, not normal postpartum changes. Choice B is also incorrect as increased frequency of urination after vaginal delivery could indicate a urinary tract infection, not a normal postpartum change. Choice C is incorrect because running a low-grade temperature for a few days is not expected postpartum; an elevated temperature above 100°F should be reported to the physician as it could indicate infection.