Nokea
A nurse is planning care for a client who has a lump in their right breast. Which of the following findings increases the clients risk of developing breast cancer?
- A. Daily caffeine consumption
- B. A history of seasonal allergies
- C. Oral contraceptives were taken for the last 6 years
- D. Routine use of multivitamins
Correct Answer: C
Rationale: The correct answer is C: Oral contraceptives were taken for the last 6 years. Long-term use of oral contraceptives has been associated with a slightly increased risk of developing breast cancer. Estrogen and progesterone in oral contraceptives can stimulate the growth of breast tissue, potentially leading to cancer over time. Daily caffeine consumption (choice A) and a history of seasonal allergies (choice B) do not have a direct correlation with an increased risk of breast cancer. Routine use of multivitamins (choice D) is generally not linked to an increased risk of breast cancer.
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A nurse is completing an admission assessment for a client who has bacterial meningitis. Which of the following personal protective equipment should the nurse use while caring for the client?
- A. Surgical mask
- B. N95 respirator
- C. Sterile gloves
- D. Gown and face shield
Correct Answer: A
Rationale: The correct answer is A: Surgical mask. The nurse should use a surgical mask when caring for a client with bacterial meningitis to prevent the spread of infectious droplets. A surgical mask is sufficient for this infection, as it primarily spreads through respiratory droplets. Using an N95 respirator, sterile gloves, or a gown and face shield would be unnecessary and excessive for this particular situation, as they are typically reserved for airborne precautions or when there is a high risk of contact with bodily fluids. Thus, the use of a surgical mask is the most appropriate and effective choice in this scenario.
A nurse is caring for a client who has chronic venous insufficiency. Which of the following areas should the nurse assess for the presence of a venous ulcer?
- A. Tip of the toes
- B. Medial malleolus (ankle)
- C. Ball of the foot
- D. Heel of the foot
Correct Answer: B
Rationale: The correct answer is B: Medial malleolus (ankle). Venous ulcers commonly occur in areas where there is poor circulation, such as the lower legs. The medial malleolus is a common site for venous ulcers in individuals with chronic venous insufficiency due to pooling of blood in the lower extremities. Assessing this area is crucial for early detection and appropriate management. Choices A, C, and D are incorrect as venous ulcers typically develop in areas with high venous pressure and poor circulation, such as the lower legs, not at the tip of the toes, ball of the foot, or heel.
A nurse is caring for a client who is 3 hr postoperative and exhibiting signs of hypovolemia. Which of the following findings should the nurse identify as a manifestation of hypovolemia?
- A. Rapid pulse rate
- B. Bradycardia
- C. Hypertension
- D. Peripheral edema
Correct Answer: A
Rationale: The correct answer is A: Rapid pulse rate. Following surgery, hypovolemia can occur due to fluid loss. A rapid pulse rate is a common manifestation of hypovolemia as the body compensates for decreased blood volume by increasing heart rate to maintain perfusion. Bradycardia (B) is unlikely with hypovolemia as the body tries to increase cardiac output. Hypertension (C) is not typical in hypovolemia as blood pressure tends to decrease. Peripheral edema (D) is associated with fluid overload, not hypovolemia.
A nurse is assessing a client who has suspected appendicitis. Which of the following manifestations should the nurse expect? (Select all that apply.)
- A. Right lower quadrant pain
- B. Rebound tenderness
- C. Nausea and vomiting
- D. Elevated blood glucose
- E. Hypotension
Correct Answer: A, B, C
Rationale: The correct manifestations for suspected appendicitis are A, B, and C. A is correct as appendicitis typically presents with right lower quadrant pain due to inflammation of the appendix. B is correct as rebound tenderness, which is pain upon release of pressure on the abdomen, is a classic sign of appendicitis. C is correct as nausea and vomiting are common symptoms due to irritation of the gastrointestinal tract. D and E are incorrect as elevated blood glucose and hypotension are not commonly associated with appendicitis.
A nurse is providing teaching about health promotion activities for a client who has a new diagnosis of type 1 diabetes mellitus. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will eat a high-protein diet before exercise.
- B. I will check my blood sugar level before exercising.
- C. I will avoid all forms of sugar.
- D. I will only take my insulin when I feel symptoms of high blood sugar.
Correct Answer: B
Rationale: Correct Answer: B
Rationale:
1. Checking blood sugar before exercise is crucial for individuals with type 1 diabetes to prevent hypoglycemia.
2. It allows the client to adjust their insulin dosage or carbohydrate intake based on their blood sugar level.
3. Monitoring blood sugar helps maintain safe levels during physical activity.
4. Other choices are incorrect as high-protein diet may not be necessary, avoiding all sugar is extreme, and insulin should be taken as prescribed, not based on symptoms.