Nokea
A female client who has a urinary diversion tells the nurse, 'This urinary pouch is embarrassing. Everyone will know that I'm not normal. I don't see how I can go out in public anymore.' The most appropriate nursing diagnosis for this client is:
- A. Anxiety related to the presence of a urinary diversion.
- B. Deficient knowledge about how to care for the urinary diversion.
- C. Low self-esteem related to feelings of worthlessness.
- D. Unstuffed body image related to creation of a urinary diversion.
Correct Answer: D
Rationale: The client's statement reflects distress about the urinary diversion's impact on her appearance and social life, indicating a disturbed body image.
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The client in balanced suspension traction is transported to surgery for closed reduction and internal fixation of his fractured femur. Which of the following should the nurse do when transporting the client to the operating room?
- A. Transfer the client to a cart with manually suspended traction.
- B. Call the surgeon to request an order to temporarily remove the traction.
- C. Send the client on his bed with extra help to stabilize the traction.
- D. Remove the traction and send the client on a cart.
Correct Answer: C
Rationale: Transporting on the bed with extra help maintains traction stability, preventing fracture displacement.
A 17-year-old, sexually active female client is seen in the family planning clinic and requests hormonal contraceptives. Before examination, the nurse should explain the importance of regular Papanicolaou (Pap) smears. This recommendation is based on the current screening guidelines of the American Cancer Society for Pap smears, which state that:
- A. Pap smears are recommended every other year.
- B. If four consecutive annual Pap smears are negative, the client should schedule repeat Pap smears every 3 years.
- C. The initial Pap smear should be done at age 12.
Correct Answer: B
Rationale: American Cancer Society guidelines recommend Pap smears every 3 years after four consecutive normal annual smears for women who are sexually active or over 21. Screening does not start at age 12, and every-other-year screening is not standard.
A client receiving vent-assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. The nurse should:
- A. Count the rate to be sure that ventilations are deep enough to be sufficient.
- B. Notify the physician of the client's breathing pattern.
- C. Increase the rate of ventilations.
- D. Increase the tidal volume on the ventilator.
Correct Answer: B
Rationale: Cluster breathing, a sign of neurological deterioration, requires immediate physician notification for evaluation and possible intervention. Adjusting ventilator settings without medical orders is inappropriate, and simply counting the rate does not address the underlying issue.
Which assessment is critical for a client with a recent stroke?
- A. Swallowing ability.
- B. Blood glucose.
- C. Cholesterol levels.
- D. Joint mobility.
Correct Answer: A
Rationale: Assessing swallowing ability is critical to prevent aspiration in stroke patients.
The nurse is teaching a client with a new colostomy about dietary modifications. Which of the following foods should the client avoid to prevent excessive gas?
- A. Broccoli.
- B. Chicken.
- C. Rice.
- D. Yogurt.
Correct Answer: A
Rationale: Broccoli, a cruciferous vegetable, can cause excessive gas in clients with a colostomy, which may lead to pouch ballooning. Chicken, rice, and yogurt are less likely to produce significant gas. CN: Physiological adaptation; CL: Synthesize