Nokea
A nurse is inserting an indwelling urinary catheterfor a male patient. Which action will the nurse take?
- A. Hold the shaft of the penis at a 60-degree angle.
- B. Hold the shaft of the penis with the dominant hand.
- C. Cleanse the meatus 3 times with the same cotton ball from clean to dirty.
- D. Cleanse the meatus with circular strokes beginning at the meatus and working outward.
Correct Answer: D
Rationale: The correct answer is D because cleansing the meatus with circular strokes starting at the meatus and moving outward helps prevent the introduction of bacteria into the urethra. This technique minimizes the risk of urinary tract infections. Holding the shaft at a 60-degree angle (A) or with the dominant hand (B) is not necessary for catheter insertion. Cleansing the meatus 3 times with the same cotton ball (C) can introduce more bacteria and is not recommended.
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An adolescent is identified as having a collection of fluid in the tunica vaginalis of his testes. The nurse knows that this adolescent will receive what medical diagnosis?
- A. Cryptorchidism
- B. Orchitis
- C. Hydrocele
- D. Prostatism
Correct Answer: C
Rationale: The correct answer is C: Hydrocele. A hydrocele is the collection of fluid in the tunica vaginalis of the testes. This condition is common in newborns and can also occur in adolescents. Cryptorchidism (A) is the absence of one or both testes from the scrotum. Orchitis (B) is inflammation of the testicles. Prostatism (D) is a non-specific term related to prostate issues, not relevant to the given scenario. Therefore, the correct diagnosis for an adolescent with fluid collection in the tunica vaginalis of his testes is hydrocele.
A nurse is designing a form for lesbian, gay,bisexual, and transgender (LGBT) patients. Which design should the nurse use?
- A. Use partnered rather than married.
- B. Use mother rather than father.
- C. Use parents rather than guardian.
- D. Use wife/husband rather than significant other.
Correct Answer: C
Rationale: The correct answer is C: Use parents rather than guardian. This is the most inclusive and respectful choice for LGBT patients as it acknowledges different family structures. LGBT individuals may have non-traditional family dynamics, so using "parents" instead of "guardian" is more appropriate. Option A is incorrect because not all LGBT individuals are in partnerships. Option B is incorrect as it assumes traditional gender roles. Option D is incorrect as not all LGBT individuals may identify with the terms "wife" or "husband."
A nurse is preparing to document a patient whohas chest pain. Which information is critical for the nurse to include?
- A. The family is a “pain.”
- B. Pupils equal and reactive to light
- C. Had poor results from the pain medication
- D. Sharp pain of 8 on a scale of 1 to 10
Correct Answer: D
Rationale: The correct answer is D because documenting the patient's pain intensity using a pain scale (8 out of 10) is crucial for assessing the severity of the chest pain. This information helps in determining the appropriate intervention and monitoring the effectiveness of treatment. Choice A is irrelevant as it does not provide any useful information about the patient's condition. Choice B is important for neurological assessment but not specifically related to chest pain. Choice C is not as critical as knowing the current pain level.
You are caring for a patient, a 42-year-old mother of two children, with a diagnosis of ovarian cancer. She has just been told that her ovarian cancer is terminal. When you admitted this patient, you did a spiritual assessment. What question would it have been most important for you to evaluate during this assessment?
- A. Is she able to tell her family of negative test results?
- B. Does she have a sense of peace of mind and a purpose to her life?
- C. Can she let go of her husband so he can make a new life?
- D. Does she need time and space to bargain with God for a cure?
Correct Answer: B
Rationale: The correct answer is B: Does she have a sense of peace of mind and a purpose to her life? This question is crucial during a spiritual assessment because it addresses the patient's emotional well-being and coping mechanisms in the face of a terminal diagnosis. It helps assess the patient's spiritual beliefs, values, and sources of strength, which can impact their ability to find meaning and comfort during difficult times. It also provides insights into the patient's resilience and ability to navigate their emotions and find peace amidst uncertainty.
Choice A is incorrect because it focuses on the patient's ability to deliver negative news to her family, which is important but not as central to the patient's spiritual well-being in this context. Choice C is incorrect as it assumes the patient needs to let go of her husband, which may not be relevant to her spiritual assessment. Choice D is incorrect as it centers on bargaining with God for a cure, which may not be reflective of the patient's spiritual beliefs or needs.
Following a recent history of dyspareunia and lower abdominal pain, a patient has received a diagnosis of pelvic inflammatory disease (PID). When providing health education related to self-care, the nurse should address which of the following topics? Select all that apply.
- A. Use of condoms to prevent infecting others
- B. Appropriate use of antibiotics
- C. Taking measures to prevent pregnancy
- D. The need for a Pap smear every 3 months E) The importance of weight loss in preventing symptoms
Correct Answer: A
Rationale: The correct answer is A: Use of condoms to prevent infecting others. This is important because PID is a sexually transmitted infection and using condoms can help prevent transmission to sexual partners. It is crucial to address this topic to ensure the patient understands the importance of safe sex practices.
The other choices are incorrect:
B: Appropriate use of antibiotics - While antibiotics are used to treat PID, this choice does not address self-care education for prevention.
C: Taking measures to prevent pregnancy - While important for overall health, preventing pregnancy is not directly related to self-care for PID.
D: The need for a Pap smear every 3 months - Pap smears are not directly related to PID management or prevention.
E: The importance of weight loss in preventing symptoms - Weight loss is not a direct self-care measure for managing or preventing PID.