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A nurse at a community-based health fair is promoting having a routine Papanicolaou test (Pap smear) to young adult women. Which of the following types of preventive care is the Pap smear?
- A. Primary level
- B. Secondary level
- C. Tertiary level
- D. Self-care ability level.
Correct Answer: B
Rationale: The correct answer is B: Secondary level preventive care. A Pap smear is a screening test that aims to detect precancerous or cancerous cells in the cervix at an early stage. This type of preventive care falls under secondary prevention because it focuses on early detection and treatment of disease before it progresses. Primary prevention (choice A) aims to prevent the disease from occurring in the first place. Tertiary prevention (choice C) focuses on managing and reducing the impact of the disease after it has already developed. Self-care ability level (choice D) is not a recognized level of preventive care.
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A nurse is measuring the vital signs of a client he suspects has hypovolemic shock. Which of the following findings should the nurse expect?
- A. High BP and low pulse rate
- B. Low BP and low pulse rate
- C. High BP and high pulse rate
- D. Low BP and high pulse rate
Correct Answer: D
Rationale: Hypovolemic shock leads to decreased blood pressure due to fluid loss and compensatory tachycardia.
A nurse is collecting data from the mother of a toddler. Which of the following activities should the nurse expect the toddler to be able to perform?
- A. Jump rope
- B. Ride a tricycle
- C. Print letters and numbers
- D. Use scissors to cut out a picture
Correct Answer: B
Rationale: The correct answer is B: Ride a tricycle. Toddlers typically develop the coordination and balance needed to ride a tricycle around the age of 3. This activity helps improve gross motor skills and coordination. Jumping rope (A) requires more advanced motor skills and coordination. Printing letters and numbers (C) involves fine motor skills that develop later. Using scissors to cut out a picture (D) also requires more advanced fine motor skills and hand-eye coordination.
A nurse is planning to reinforce teaching with a client who has a low health literacy level. Which of the following methods should the nurse use?
- A. Provide four important points.
- B. Explain information using passive voice.
- C. Use third person.
- D. Have two information sessions.
Correct Answer: A
Rationale: The correct answer is A because providing four important points can help simplify and organize information for a client with low health literacy. Breaking down information into key points can enhance understanding and retention. Choice B using passive voice may confuse the client. Choice C using third person may create distance and hinder engagement. Choice D having two information sessions could overwhelm the client. In summary, choice A is the most effective method for reinforcing teaching with a client with low health literacy.
A nurse plans to reinforce discharge teaching with a client. Of the following barriers to learning the nurse identifies with this client, which should the nurse interpret as a need to postpone the session?
- A. Pain
- B. Hearing loss
- C. The client's culture
- D. Motor impairment
Correct Answer: A
Rationale: The correct answer is A. Pain can significantly impact a client's ability to concentrate and retain information during a teaching session. Pain can cause distress, affecting the client's focus and ability to engage in the learning process. Therefore, addressing pain as a priority before proceeding with discharge teaching is essential.
Hearing loss (B) can be accommodated with visual aids or written materials. Cultural considerations (C) can be integrated into the teaching plan. Motor impairment (D) can also be managed by providing alternative methods for learning. Other choices are not as critical as pain in hindering the learning process.
A nurse is collecting data from a client who is 2 days postoperative. The nurse auscultates bilateral breath sounds but absent breath sounds in the bases. The nurse should suspect which of the following postoperative complications?
- A. Atelectasis
- B. Rales
- C. Rhonchi
- D. Pneumothorax
Correct Answer: A
Rationale: Atelectasis causes absent breath sounds in lung bases due to alveolar collapse.