Nokea
A nurse is caring for a client who is postoperative following a mastectomy. The client expresses concern that they will no longer be attractive to their partner. Which of the following actions should the nurse take?
- A. Discourage the client from looking at their breasts.
- B. Recommend a support group for the client to attend.
- C. Tell the client you are so sorry for how devastated they must feel.
- D. Tell the client to focus on their postoperative recovery for now.
Correct Answer: B
Rationale: Recommending a support group provides psychosocial support, enabling clients to share experiences and gain insights from peers, which can alleviate feelings of inadequacy and encourage acceptance of body image changes.
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A nurse is teaching a client about using an intrauterine device (IUD) for contraception. Which of the following client statements indicates an understanding of the teaching?
- A. I will need to have the IUD replaced each year.
- B. I will need to apply a spermicide prior to intercourse.
- C. I should expect my periods to stop while I have the IUD.
- D. I should check for the string each month after menstruation.
Correct Answer: D
Rationale: Checking for the string ensures proper IUD positioning and functionality. This monthly practice helps detect dislodgement or expulsion, which can compromise contraceptive effectiveness.
A nurse is providing teaching to a client about the Papanicolaou (Pap) test. Which of the following information should the nurse include in the teaching?
- A. A yearly Pap test is recommended until 70 years of age.
- B. Pap tests are discontinued following removal of the ovaries.
- C. Avoid having sexual intercourse for 24 hours prior to the Pap test.
- D. Viral infections can be detected by a Pap test.
Correct Answer: C
Rationale: Avoiding intercourse for 24 hours minimizes contamination of cervical cells with external materials, ensuring accurate Pap test results. It is an important preparatory guideline.
A nurse is admitting a client who is at 33 weeks of gestation and has preeclampsia with severe features. Which of the following actions should the nurse take?
- A. Restrict protein intake to less than 40 g/day.
- B. Initiate seizure precautions for the client.
- C. Encourage the client to ambulate twice per day.
- D. Initiate an infusion of 0.9% sodium chloride at 150 mL/hr.
Correct Answer: B
Rationale: Seizure precautions are necessary in preeclampsia due to the risk of eclampsia from uncontrolled blood pressure. Measures include bedrails padding and medication administration to reduce seizure occurrences.
For each body system below, specify the potential complications that can occur. Match the body system with the potential complications.
- A. Hypotonia
- B. Seizures
- C. Hearing loss
Correct Answer: B
Rationale: Neurologic: Seizures (B) - due to potential neurological dysfunction. Musculoskeletal: Hypotonia (A) - indicating muscle weakness. Head, ears, eyes, nose, and throat: Hearing loss (C) - from auditory nerve or structural damage.
A nurse is caring for a client. Which of the following interventions should the nurse perform?
- A. Inspect the perineum.
- B. Massage the fundus.
- C. Administer oxytocin.
- D. Assist the client to void.
Correct Answer: B
Rationale: Massaging the fundus stimulates uterine contractions, reducing uterine atony and preventing further hemorrhage. This is a first-line intervention for postpartum excessive bleeding.