Nokea
A nurse is reinforcing teaching with a 40-year-old female client about preventive health screenings. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should have my skin checked every 5 years for cancer.
- B. I will need to have a mammogram every year now.
- C. I should have my first colonoscopy when I turn 65.
- D. I will be checked for uterine cancer every 2 years.
Correct Answer: B
Rationale: The correct answer is B: "I will need to have a mammogram every year now." Mammograms are recommended for women starting at age 40 to screen for breast cancer. Annual mammograms help detect any abnormalities early, improving the chances of successful treatment. Choice A is incorrect as skin checks should be done annually. Choice C is incorrect as the first colonoscopy is usually recommended at age 50. Choice D is incorrect as there is no standard screening for uterine cancer every 2 years.
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A nurse is caring for a client who had a severe traumatic brain injury 3 weeks ago, remains unconscious, and is unlikely to recover. While bathing the client, the assistive personnel (AP) talks to him about current events. The client's partner asks the nurse why the AP talks to the client. Which of the following responses should the nurse make?
- A. I'm really not sure why the assistant is talking to him. Perhaps you should ask her.
- B. Although your partner is not responding to us, he might still be able to hear.
- C. Don't let that concern you. She talks to all her clients, no matter what.
- D. She is an excellent caregiver. She has many others to care for, but she takes the time to talk to your partner.
Correct Answer: B
Rationale: The correct answer is B: Although your partner is not responding to us, he might still be able to hear. This response is correct because research shows that comatose patients can still hear and process information. Talking to the patient can provide comfort, familiarity, and potentially stimulate brain activity.
Choices A, C, and D are incorrect because they do not address the potential benefit of talking to the unconscious patient. A deflects the question, C generalizes the behavior, and D praises the caregiver without explaining the rationale behind talking to the patient.
In summary, choice B is the best response as it acknowledges the potential for the unconscious patient to hear and emphasizes the importance of continuing communication for the patient's well-being.
A nurse is caring for an older adult client who has confusion and weakness. The client has a Hct of 53%, a BUN of 25 mg/dL, and a urine specific gravity of 1.232. Which of the following actions should the nurse contribute to the client's plan of care?
- A. Restrict the client's fluid intake.
- B. Monitor the client's intake and output.
- C. Weigh the client daily.
- D. Instruct the client to sit on the side of the bed for a few minutes before standing.
- E. Check the client's orientation to person, place, and time regularly.
Correct Answer: B,C,E
Rationale: The lab values suggest dehydration, so monitoring fluid balance and orientation is essential.
A nurse is contributing to the plan of care for a client who is a Seventh-Day Adventist. To provide spiritually and culturally sensitive care, which of the following interventions should the nurse suggest for this client?
- A. Do not schedule diagnostic tests for Saturday.
- B. Arrange for him to receive the sacrament of the sick.
- C. Assign same-gender caregivers.
- D. Offer him a kosher dietary menu.
Correct Answer: A
Rationale: The correct answer is A: Do not schedule diagnostic tests for Saturday. Seventh-Day Adventists observe Saturday as a holy day of rest and worship, known as the Sabbath. By avoiding scheduling diagnostic tests on Saturdays, the nurse respects the client's religious beliefs and practices. This intervention promotes culturally sensitive care by acknowledging and accommodating the client's spiritual needs.
Choice B (Arrange for him to receive the sacrament of the sick) is incorrect as this intervention is specific to the Catholic faith, not Seventh-Day Adventist beliefs. Choice C (Assign same-gender caregivers) is not directly related to the client's religious preferences and may not be necessary for providing culturally sensitive care in this context. Choice D (Offer him a kosher dietary menu) is more aligned with Jewish dietary laws, which do not specifically apply to Seventh-Day Adventist beliefs.
A nurse is collecting data about a client's pulmonary system. While auscultating the client's lungs, the nurse hears continuous gurgling, low-pitched sounds over the trachea and bronchi. Which of the following terms should the nurse use to document this finding?
- A. Rhonchi
- B. Crackles
- C. Wheezing
- D. Friction rub
Correct Answer: A
Rationale: The correct answer is A: Rhonchi. Rhonchi are continuous low-pitched gurgling sounds heard over the trachea and bronchi. These sounds are typically caused by the movement of air through narrowed airways due to secretions or inflammation. Crackles (B) are discontinuous, popping sounds typically heard during inspiration and caused by fluid in the alveoli. Wheezing (C) is a high-pitched musical sound heard on expiration and caused by narrowed airways. Friction rub (D) is a grating, rubbing sound heard during inspiration and expiration and is typically associated with inflammation of the pleura.
A nurse is caring for a client who has cancer and is receiving palliative care. Which of the following statements should the nurse identify as an indication that the client understands and accepts his prognosis?
- A. I am thinking of getting a second opinion.
- B. I am hoping this will help relieve my discomfort.
- C. This is making me stronger every day.
- D. This is not working, and I plan to stop treatment.
Correct Answer: B
Rationale: Palliative care focuses on symptom relief, and the statement reflects an understanding of this goal.