Nokea
A nurse at a community health clinic is assisting with creating a brochure about testicular cancer. Which of the following information should the nurse include?
- A. Perform a testicular self-examination twice per year.
- B. Palpate the epididymis.
- C. Gently roll the testicles to feel for abnormalities.
- D. Use one hand to palpate the testicles.
Correct Answer: C
Rationale: The correct answer is C: Gently roll the testicles to feel for abnormalities. This is the most appropriate information to include in the brochure because gently rolling the testicles between the thumb and fingers is the recommended technique for testicular self-examination. By rolling the testicles, individuals can better detect any lumps or changes in texture that may indicate testicular cancer.
Choice A is incorrect because the current recommendation is to perform testicular self-exams monthly, not twice per year. Choice B is incorrect as palpating the epididymis is not part of the standard testicular self-examination procedure. Choice D is incorrect because using both hands is recommended for better examination.
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A nurse is caring for a client who had a severe traumatic brain injury 3 weeks ago, remains unconscious, and is unlikely to recover. While bathing the client, the assistive personnel (AP) talks to him about current events. The client's partner asks the nurse why the AP talks to the client. Which of the following responses should the nurse make?
- A. I'm really not sure why the assistant is talking to him. Perhaps you should ask her.
- B. Although your partner is not responding to us, he might still be able to hear.
- C. Don't let that concern you. She talks to all her clients, no matter what.
- D. She is an excellent caregiver. She has many others to care for, but she takes the time to talk to your partner.
Correct Answer: B
Rationale: The correct answer is B: Although your partner is not responding to us, he might still be able to hear. This response is correct because research shows that comatose patients can still hear and process information. Talking to the patient can provide comfort, familiarity, and potentially stimulate brain activity.
Choices A, C, and D are incorrect because they do not address the potential benefit of talking to the unconscious patient. A deflects the question, C generalizes the behavior, and D praises the caregiver without explaining the rationale behind talking to the patient.
In summary, choice B is the best response as it acknowledges the potential for the unconscious patient to hear and emphasizes the importance of continuing communication for the patient's well-being.
A nurse on a medical unit is caring for a client who requires seizure precautions. Which of the following interventions should the nurse contribute to the client's plan of care?
- A. Restrain the client as soon as seizure activity begins.
- B. Keep the lights on when the client is sleeping.
- C. Keep the client's bed in the lowest position.
- D. Have a padded tongue depressor available at the bedside.
Correct Answer: C
Rationale: The correct answer is C: Keep the client's bed in the lowest position. This is important for client safety during a seizure as it reduces the risk of injury from falling out of bed. Keeping the bed low ensures a shorter fall distance and minimizes the impact. Restraint (choice A) is not recommended as it can lead to further injury during a seizure. Keeping lights on (choice B) can trigger seizures in some individuals. Having a padded tongue depressor available (choice D) is not relevant to seizure precautions.
A nurse is assisting with the admission of a client who is dehydrated. Which of the following BUN levels should the nurse expect the client to have?
- A. 3.6 mg/dL
- B. 9 mg/dL
- C. 18.7 mg/dL
- D. 24 mg/dL
Correct Answer: D
Rationale: The correct answer is D: 24 mg/dL. BUN (Blood Urea Nitrogen) levels typically increase in dehydration due to reduced kidney perfusion. A BUN level of 24 mg/dL is higher than normal (7-20 mg/dL) and is indicative of dehydration. Choice A (3.6 mg/dL) is too low for a dehydrated client. Choice B (9 mg/dL) is within the normal range and not high enough for dehydration. Choice C (18.7 mg/dL) is slightly elevated but may not be as indicative of dehydration as choice D.
A nurse is caring for four clients who have drainage tubes. The nurse should identify the client who has which of the following tubes as being at risk for hypokalemia?
- A. An NG tube to suction
- B. An indwelling urinary catheter to gravity drainage
- C. A chest tube to water-seal drainage
- D. A nephrostomy tube to a drainage bag
Correct Answer: A
Rationale: NG suction removes gastric contents, leading to loss of potassium and increased risk of hypokalemia.
A nurse in an extended-care facility is reinforcing teaching with a group of newly licensed nurses about the expected physiologic changes of aging. Which of the following information should the nurse include? (Select all that apply.)
- A. More difficulty seeing due to a greater sensitivity to glare
- B. Decreased cough reflex
- C. Decreased bladder capacity
- D. Decreased systolic blood pressure
- E. Dehydration of intervertebral discs
Correct Answer: A,B,C,E
Rationale: Correct Answer: A, B, C, E
Rationale:
A: With aging, the lens of the eye becomes less flexible, leading to difficulty seeing due to glare.
B: Aging affects the cough reflex, making it less effective in clearing the respiratory tract.
C: Bladder capacity decreases with age due to decreased muscle tone and elasticity.
E: Intervertebral discs lose water content with age, leading to dehydration and decreased flexibility.
Incorrect Choices:
D: Systolic blood pressure tends to increase with age, not decrease.
F, G: No information provided to analyze these options.