Nokea
A nurse is reinforcing teaching about self-care with a client who has pelvic inflammatory disease. The client does not speak English. Which of the following actions by the nurse is appropriate?
- A. Ask the client's English-speaking family member to translate.
- B. Use a translation dictionary to reinforce the teaching.
- C. Seek assistance from a facility-approved interpreter.
- D. Ask an assistive personnel (AP) who speaks the client's language to serve as an interpreter.
- G. C
Correct Answer: A facility-approved interpreter ensures accurate and confidential communication. Family members may lack medical knowledge, dictionaries are inefficient, and APs may not be qualified or authorized to interpret.
Rationale:
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A nurse is assessing a female client and suspects that the client may have endometrial polyps based on which clinical manifestation?
- A. Bleeding between menses
- B. Bleeding after intercourse
- C. Metrorrhagia
- D. Vaginal discharge
- G. C
Correct Answer: Metrorrhagia (irregular uterine bleeding) is a hallmark of endometrial polyps due to their disruption of the endometrium. Other symptoms are less specific.
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A nurse is reading a journal article about the care of a woman with pelvic organ prolapse. Would expect to find information on which disorder. Select all that apply.
- A. Rectal incontinence
- B. Rectocele
- C. Urinary incontinence
- D. Cystocele
- E. Enterocele
- G. B,C,D,E
Correct Answer: Pelvic organ prolapse involves disorders like rectocele (rectum bulging into vagina), urinary incontinence (bladder control loss), cystocele (bladder bulging into vagina), and enterocele (small intestine bulging into vagina). Rectal incontinence is not directly related.
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A nurse is caring for a client who is 4 days postoperative following a right radical mastectomy. Which of the following activities should the nurse anticipate being the most difficult for this client to perform with her right hand?
- A. Brushing her teeth
- B. Buttoning her blouse
- C. Eating her breakfast
- D. Combing her hair
- G. D
Correct Answer: Combing hair requires lifting the arm above the shoulder, which can be painful and difficult due to impaired lymphatic drainage and nerve damage post-mastectomy. Brushing teeth, buttoning a blouse, and eating are less challenging as they require minimal arm elevation or strength.
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Which finding would the nurse expect in a client with bacterial vaginosis?
- A. Vaginal pH of 3
- B. Cervical bleeding on contact
- C. Fishy odor of discharge
- D. Yellowish-green discharge
- G. C
Correct Answer: Bacterial vaginosis causes a fishy-smelling, thin, gray-white discharge due to anaerobic bacteria. Vaginal pH rises above 4.5, cervical bleeding suggests other issues, and yellowish-green discharge indicates other infections.
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The nurse is assessing a 13-year-old girl. Which event would the nurse expect to have occurred first?
- A. Growth spurt
- B. Evidence of pubic hair
- C. Onset of menses
- D. Development of breast buds
- G. D
Correct Answer: Breast bud development (thelarche) is typically the first pubertal event in girls, occurring between 8-12 years, driven by estrogen.
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