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A nurse is providing teaching to a client about the manifestations of uterine prolapse. Which of the following statements by the client should indicate to the nurse a need for further teaching?
- A. I should avoid heavy lifting.
- B. Feces can be present in the vagina.
- C. I might experience urinary incontinence.
- D. Pelvic pressure may occur during intercourse.
Correct Answer: B
Rationale: The correct answer is B. Feces present in the vagina is not a manifestation of uterine prolapse; it is a symptom of rectocele. The other choices are correct for uterine prolapse: A - Heavy lifting can worsen prolapse, C - Urinary incontinence is common due to pelvic floor weakness, D - Pelvic pressure during intercourse is a symptom. Therefore, the client mentioning feces in the vagina indicates a need for further teaching on distinguishing between uterine prolapse and rectocele symptoms.
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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 presenting a community-based program about HIV and AIDS. A client asks the nurse to describe the initial symptoms experienced with HIV infection. Which of the following manifestations should the nurse include in the explanation of initial symptoms?
- A. Abdominal cramps and diarrhea
- B. Persistent cough and chest pain
- C. Flu-like symptoms and night sweats
- D. Severe fatigue and weight loss
Correct Answer: C
Rationale: The correct answer is C: Flu-like symptoms and night sweats. Initial symptoms of HIV infection often resemble flu-like symptoms such as fever, fatigue, sore throat, swollen lymph nodes, and night sweats. This occurs because the virus is rapidly replicating in the body and the immune system is reacting to it. The other choices, abdominal cramps and diarrhea (A), persistent cough and chest pain (B), and severe fatigue and weight loss (D), are more commonly associated with later stages of HIV infection or other conditions. Therefore, the nurse should include flu-like symptoms and night sweats in the explanation of initial symptoms to accurately inform the client.
A nurse is reviewing the laboratory results of a client who has a pressure ulcer. The nurse should identify an elevation in which of the following laboratory values as an indication that the client has developed an infection?
- A. Serum albumin level
- B. WBC count
- C. Serum potassium level
- D. BUN
Correct Answer: B
Rationale: The correct answer is B: WBC count. An elevation in WBC count indicates an immune response to infection, as white blood cells increase to fight off pathogens. In the context of a pressure ulcer, an elevated WBC count suggests the presence of infection due to the body's response to foreign organisms. Other choices are not directly related to infection in this scenario. Serum albumin level (A) reflects nutritional status, serum potassium level (C) indicates electrolyte balance, and BUN (D) reflects kidney function. Hence, they are not specific indicators of infection in a client with a pressure ulcer.
A nurse is providing teaching to a client who has had a total abdominal hysterectomy and bilateral salpingo-oophorectomy for uterine cancer. Which of the following instructions should the nurse include in the teaching?
- A. Artificial lubrication can be used to treat vaginal itching and dryness.
- B. Avoid sexual activity for the first 6 months.
- C. Use a menstrual pad for vaginal bleeding.
- D. Use a diaphragm for contraception.
Correct Answer: A
Rationale: The correct answer is A: Artificial lubrication can be used to treat vaginal itching and dryness. The rationale for this is that after a total abdominal hysterectomy and bilateral salpingo-oophorectomy, there is a decrease in estrogen levels, leading to vaginal dryness and itching. Using artificial lubrication can help alleviate these symptoms and improve comfort.
Choice B is incorrect as there is no need to avoid sexual activity for 6 months unless specifically advised by the healthcare provider. Choice C is incorrect as there should not be vaginal bleeding after a total abdominal hysterectomy. Choice D is incorrect as using a diaphragm for contraception is not recommended after a hysterectomy.
A nurse is caring for a client who has had a spinal cord injury at the level of the T2-T3 vertebrae. When planning care, the nurse should anticipate which of the following types of disability?
- A. Paraplegia
- B. Tetraplegia
- C. Quadriplegia
- D. Hemiplegia
Correct Answer: A
Rationale: The correct answer is A: Paraplegia. Damage at the T2-T3 vertebrae level affects the lower part of the body, resulting in paralysis of the legs and potentially part of the trunk (paraplegia). This injury does not affect the arms or hands, ruling out tetraplegia (B) and quadriplegia (C). Hemiplegia (D) refers to paralysis on one side of the body only, which is not the case here. Other choices are not applicable.