Nokea
A nurse evaluates a client's PSA lab results. An increase in PSA indicates what condition?
- A. Benign prostatic hyperplasia
- B. Prostatic cancer
- C. Urinary tract infection
- D. Kidney stones
Correct Answer: B
Rationale: The correct answer is B: Prostatic cancer. PSA levels are commonly used as a marker for prostate cancer. Elevated PSA levels indicate an increased likelihood of prostate cancer. Benign prostatic hyperplasia (choice A) is a non-cancerous condition that can also cause elevated PSA levels but is not indicative of cancer. Urinary tract infection (choice C) and kidney stones (choice D) do not directly affect PSA levels. The other choices (E, F, G) are not provided, but the key is to understand that an increase in PSA specifically points towards the possibility of prostatic cancer.
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A nurse is admitting a client who has a serum calcium level of 12.3 mg/dL and initiates cardiac monitoring. Which of the following findings should the nurse expect during the initial assessment?
- A. Lethargy
- B. Hypertension
- C. Muscle spasms
- D. Severe agitation
Correct Answer: A
Rationale: The correct answer is A: Lethargy. A serum calcium level of 12.3 mg/dL indicates hypercalcemia. In hypercalcemia, calcium affects the central nervous system, leading to lethargy, weakness, and confusion. Lethargy is a common early symptom of hypercalcemia. Hypertension is not typically associated with hypercalcemia. Muscle spasms are more common in hypocalcemia. Severe agitation is not a typical manifestation of hypercalcemia.
A nurse is reviewing discharge instructions with a client following a right cataract extraction. Which of the following instructions should the nurse include?
- A. Avoid lifting anything heavier than 4.5 kg (10 lb) for 1 week.
- B. Take a warm shower every day.
- C. Resume regular activities immediately.
- D. Avoid all physical activity for the next month.
Correct Answer: A
Rationale: The correct answer is A: Avoid lifting anything heavier than 4.5 kg (10 lb) for 1 week. This instruction is crucial after a cataract extraction to prevent any strain on the eye during the initial healing period. Lifting heavy objects can increase intraocular pressure and potentially lead to complications. Choice B (Take a warm shower every day) is not directly related to post-operative care for a cataract extraction. Choice C (Resume regular activities immediately) is incorrect as the client should avoid strenuous activities, including heavy lifting, to allow proper healing. Choice D (Avoid all physical activity for the next month) is overly restrictive and unnecessary. It's important to provide specific, clear, and relevant instructions to support the client's recovery.
A nurse is caring for a client who is 2 hours postoperative following a transurethral resection of the prostate (TURP) gland. Which of the following assessments should the nurse view to be an indication of a postoperative complication?
- A. Output of dark amber urine
- B. Output of clear, light pink urine
- C. Output of bright red urine
- D. Output of burgundy colored urine
Correct Answer: D
Rationale: The correct answer is D: Output of burgundy colored urine. This indicates possible hemorrhage, a serious complication post-TURP. Dark amber urine (A) may suggest dehydration. Clear, light pink urine (B) is expected due to bladder irrigation post-TURP. Bright red urine (C) is common initially but should decrease over time. Burgundy colored urine (D) indicates active bleeding and requires immediate intervention.
A nurse is teaching a group of newly licensed nurses on effective techniques for counseling clients about sexually transmitted infections (STIs). Which of the following statements should the nurse include in the teaching?
- A. Ask about the client's exposure to any past or present STIs.
- B. Advise clients not to disclose their sexual history.
- C. Focus only on present symptoms of STIs.
- D. Only ask about high-risk behavior.
Correct Answer: A
Rationale: The correct answer is A because asking about the client's exposure to any past or present STIs is crucial for effective counseling. Understanding the client's history helps in assessing risk factors, determining appropriate interventions, and providing tailored education. It also promotes trust and open communication.
Choice B is incorrect as advising clients not to disclose their sexual history hinders the nurse's ability to provide comprehensive care and support. Choice C is incorrect because focusing only on present symptoms may overlook important information needed for proper assessment and management. Choice D is incorrect as only asking about high-risk behavior limits the scope of the assessment and may miss potential risk factors.
A nurse assesses a client in skeletal traction. What indicates infection at the pin sites?
- A. Pallor
- B. Fever
- C. Bradycardia
- D. Elevated blood pressure
Correct Answer: B
Rationale: The correct answer is B: Fever. Infection at the pin sites in skeletal traction commonly presents with systemic signs like fever. Fever is a typical response to infection as the body tries to fight off the invading pathogens. Pallor, bradycardia, and elevated blood pressure are not specific indicators of infection at pin sites. Pallor may indicate poor perfusion, bradycardia is a slow heart rate which is not typically associated with infection, and elevated blood pressure can be a response to various stressors but not a specific sign of infection at pin sites. In summary, fever is the most reliable indicator of infection at pin sites due to its systemic nature.