Nokea
A newborn male infant is diagnosed with an undescended testicle (cryptorchidism), and these findings are shared with the parents. The parents ask questions about the condition. The nurse should respond to the parents that which condition can occur and have a psychosocial impact if the undescended testicle is not corrected?
- A. Atrophy
- B. Infertility
- C. Malignancy
- D. Feminization
Correct Answer: B
Rationale: Infertility can occur in males with this condition because proper function of the testes in producing fertile sperm depends on a temperature of less than 98.6°F (37.0°C). The psychological effects of an 'empty scrotum' could affect the client's perception of self and the ability to reproduce. Options 1 and 3 are possible physical consequences of a failure to treat cryptorchidism rather than psychosocial consequences. Because all of the hormones that are responsible for secondary sex characteristics continue to be secreted directly into the bloodstream, option 4 is not correct.
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A client has been prescribed imipramine. The nurse notifies the primary health care provider if which adverse effect to the medication is noted?
- A. Increased appetite
- B. Increased drowsiness
- C. Reported decrease in anxiety
- D. Increased sense of well-being
Correct Answer: B
Rationale: Imipramine is a tricyclic antidepressant that is used to treat various forms of depression and anxiety. The client is also often in psychotherapy while prescribed this medication. Adverse effects to report to the primary health care provider include drowsiness, lethargy, and fatigue. Expected effects of the medication include an increased appetite and time spent sleeping, a reduced sense of anxiety, and an improved sense of well-being.
The nurse provides care for a client diagnosed with dementia. The nurse instructs the unlicensed assistive personnel (UAP) about bathing the client. Which strategies will the nurse identify as appropriate for the client? (Select all that apply.)
- A. Sing or talk to the client throughout the activity.
- B. Expose only one area at a time while bathing.
- C. Complete the bath as quickly as possible.
- D. Organize all supplies before starting the bath.
- E. Bathe the client slowly and explain each action.
Correct Answer: A,B,D,E
Rationale: For a client with dementia, appropriate bathing strategies include: (A) Singing or talking to provide comfort and reduce anxiety; (B) Exposing only one area to maintain dignity and prevent chilling; (D) Organizing supplies to minimize disruption; (E) Bathing slowly and explaining actions to reduce confusion. Completing the bath quickly (C) may increase agitation and is not appropriate.
The nurse is obtaining a health history from an adolescent. Which statement by the adolescent indicates a need for follow-up assessment and intervention?
- A. When I get stressed out about school, I just like to be alone.
- B. I find myself very moody. I'm happy one minute and crying the next.
- C. I don't eat any fatty foods, and I've already lost 8 pounds in 2 weeks.
- D. I can't seem to wake up in the morning. I would sleep until noon if I could.
Correct Answer: C
Rationale: During the adolescent period, there is a heightened awareness of body image and peer pressure to go on excessively restrictive diets. The extreme limitation of omitting all fat in the diet and losing weight during a time of growth suggests inadequate nutrition and a possible eating disorder. The remaining options are normal behaviors or feelings that occur during adolescence.
A female victim of a sexual assault is being seen in the crisis center for a third visit. She states that although the rape occurred nearly 2 months ago, she still feels 'as though the rape just happened yesterday.' Which statement is most appropriate for the nurse to use as a response?
- A. In reality, the rape did not just occur. It has been over 2 months now.'
- B. What can you do to alleviate some of your fears about being assaulted again?'
- C. In time, our goal will be to help you move on from these strong feelings about your rape.'
- D. Tell me more about those aspects of the rape that cause you to feel like the rape just occurred.'
Correct Answer: D
Rationale: Option 4 allows for the client to express her ideas and feelings more fully and portrays a unhurried, nonjudgmental, supportive attitude. Clients need to be reassured that their feelings are normal and that they may freely express their concerns in a safe care environment. Although option 1 is true, it immediately blocks communication. Option 2 places the problem-solving totally on the client. Option 3 places the client's feelings on hold.
A client is brought to the emergency department after overdosing on sleeping pills. The nurse is able to wake the client. Which question does the nurse ask first?
- A. Why did you take the medication?
- B. Can you share what is bothering you?
- C. How much medication did you take?
- D. Were you trying to kill yourself?
Correct Answer: C
Rationale: Determining the amount of medication taken is critical to assess the overdose’s severity and guide immediate treatment. Intent, emotional state, or reasons are secondary to ensuring physical safety.