Nokea
A client with a history of testicular cancer is admitted with complaints of back pain. The nurse should give priority to:
- A. Monitoring for metastasis
- B. Administering pain medication
- C. Monitoring blood pressure
- D. Administering chemotherapy
Correct Answer: A
Rationale: Back pain in testicular cancer may indicate metastasis to retroperitoneal lymph nodes, so monitoring for metastasis is the priority.
You may also like to solve these questions
The nurse teaches a pregnant client that a high-risk symptom occurring at any time during pregnancy that needs to be reported immediately to a healthcare provider is:
- A. Constipation
- B. Urinary frequency
- C. Breast tenderness
- D. Abdominal pain
Correct Answer: D
Rationale: Abdominal pain may be an indication of early spontaneous abortion, preterm delivery, or a placental abruption, requiring immediate medical attention.
A male client is scheduled for a liver biopsy. In preparing him for this test, the nurse should:
- A. Explain that he will be kept NPO for 24 hours before the exam
- B. Practice with him so he will be able to hold his breath for 1 minute
- C. Explain that he will be receiving a laxative to prevent a distended bowel from applying pressure on the liver
- D. Explain that his vital signs will be checked frequently after the test
Correct Answer: D
Rationale: Post-liver biopsy, vital signs are monitored frequently to detect hemorrhage or shock, the most likely complications.
The physician has ordered Dilantin (phenytoin) 100 mg intravenously for a client with generalized tonic clonic seizures. The nurse should administer the medication:
- A. Rapidly with an IV push
- B. With IV dextrose
- C. Slowly over 2-3 minutes
- D. Through a small vein
Correct Answer: C
Rationale: Phenytoin must be administered slowly (over 2-3 minutes) to prevent cardiovascular complications like hypotension or arrhythmias. It should not be mixed with dextrose or given rapidly.
A behavior-modification program has been started for an adolescent with oppositional defiant disorder. Which statement describes the use of behavior modification?
- A. Distractors are used to interrupt repetitive or unpleasant thoughts.
- B. Techniques using stressors and exercise are used to increase awareness of body defenses.
- C. A system of tokens and rewards is used as positive reinforcement.
- D. Appropriate behavior is learned through observing the action of models.
Correct Answer: C
Rationale: Behavior modification for oppositional defiant disorder often uses a token economy system, where positive behaviors are reinforced with rewards to encourage compliance.
The nurse is preparing to administer an injection to a six-month-old when she notices a white dot in the infant's right pupil. The nurse should:
- A. Report the finding to the physician immediately.
- B. Record the finding and give the infant's injection.
- C. Recognize that the finding is a variation of normal.
- D. Check both eyes for the presence of the red reflex.
Correct Answer: A
Rationale: A white dot in the pupil (leukocoria) may indicate retinoblastoma or other serious conditions, requiring immediate reporting to the physician for evaluation.