Nokea
A nurse is caring for a client who has benign prostatic hyperplasia (BPH). The nurse should expect which of the following findings?
- A. Painful urination
- B. Urge incontinence
- C. Critically elevated prostate-specific antigen (PSA) level
- D. Difficulty starting the flow of urine
Correct Answer: D
Rationale: The correct answer is D: Difficulty starting the flow of urine. This is an expected finding in a client with benign prostatic hyperplasia (BPH) due to the enlargement of the prostate gland, which can obstruct the urethra and impede the flow of urine. This commonly leads to hesitancy or difficulty initiating urination.
- A: Painful urination is not typically associated with BPH, as it is more commonly seen in conditions like urinary tract infections.
- B: Urge incontinence is not a typical finding in BPH; it is more commonly seen in conditions like overactive bladder.
- C: Critically elevated prostate-specific antigen (PSA) levels are not a direct symptom of BPH but may be used for screening and monitoring prostate cancer.
In summary, difficulty starting the flow of urine is the most relevant finding in BPH due to the mechanical obstruction caused by the enlarged prostate gland.
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A nurse is preparing to administer a bisacodyl suppository to a client. Which of the following actions should the nurse take? (Select all that apply)
- A. Don sterile gloves.
- B. Position the client supine with knees bent.
- C. Use a rectal applicator for insertion.
- D. Insert the suppository just beyond the internal sphincter.
- E. Lubricate the index finger.
Correct Answer: D,E
Rationale: The correct actions for administering a bisacodyl suppository are to insert it just beyond the internal sphincter (D) to ensure proper absorption and effectiveness. Lubricating the index finger (E) helps facilitate easier insertion and reduces discomfort for the client. Donning sterile gloves (A) is not necessary for this procedure. Positioning the client supine with knees bent (B) is not required; the Sims position is typically used. Using a rectal applicator for insertion (C) is not recommended for bisacodyl suppositories.
A nurse is assessing a client who has meningitis. Which of the following findings should the nurse expect?
- A. Blurred vision
- B. Severe headache
- C. Oriented to person, place, and year
- D. Bradycardia
Correct Answer: B
Rationale: The correct answer is B: Severe headache. Meningitis commonly presents with severe headache due to inflammation of the meninges. This is a classic symptom and should be expected during assessment. Blurred vision (A) is not a typical finding in meningitis. Being oriented to person, place, and year (C) is a sign of intact mental status, which may not be present in someone with meningitis. Bradycardia (D) is not a common finding in meningitis; tachycardia is more likely due to the body's response to infection.
A nurse is assessing a client who has chronic venous insufficiency. Which of the following findings should the nurse expect?
- A. Dependent rubor
- B. Thick, deformed toenails
- C. Hair loss
- D. Edema
Correct Answer: D
Rationale: The correct answer is D: Edema. In chronic venous insufficiency, impaired blood flow leads to fluid accumulation in the affected limb, causing swelling or edema. This occurs due to increased venous pressure and decreased venous return. Dependent rubor (choice A) is seen in arterial insufficiency, not venous. Thick, deformed toenails (choice B) and hair loss (choice C) are not typically associated with chronic venous insufficiency. Edema is a hallmark sign due to venous stasis and capillary leakage.
A nurse is providing teaching to a client with a colostomy about appropriate food choices. Which of the following foods should the nurse include in the teaching?
- A. Dried fruits
- B. Dried peas
- C. Eggs
- D. Pasta
Correct Answer: C
Rationale: The correct answer is C: Eggs. Eggs are a good source of protein, which is important for clients with a colostomy to promote healing and overall health. They are easily digestible and less likely to cause issues like blockages or gas. Dried fruits (choice A) and dried peas (choice B) can be high in fiber and may lead to digestive problems for colostomy clients. Pasta (choice D) can also be difficult to digest and may cause discomfort. Eggs are a versatile and nutritious option that can be beneficial for clients with a colostomy.
A nurse is caring for a client who suspects recent exposure to inhalation anthrax. Which of the following findings indicate possible exposure?
- A. Vesicles on the skin
- B. Respiratory failure
- C. Flu-like symptoms
- D. Coughing of blood
Correct Answer: B
Rationale: The correct answer is B: Respiratory failure. Inhalation anthrax primarily affects the respiratory system, causing symptoms such as difficulty breathing, cough, and chest discomfort. Respiratory failure can occur in severe cases. Vesicles on the skin (A) are not typically associated with inhalation anthrax. Flu-like symptoms (C) are nonspecific and can be seen with various infections. Coughing of blood (D) is not a common symptom of inhalation anthrax. Therefore, the most indicative finding of possible exposure to inhalation anthrax is respiratory failure.