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." This statement indicates an understanding of preventive health screenings for a 40-year-old female. Mammograms are recommended annually starting at age 40 to screen for breast cancer. Choice A is incorrect as skin checks for cancer should be more frequent than every 5 years. Choice C is incorrect as the first colonoscopy is recommended at age 50, not 65. Choice D is incorrect as uterine cancer screening is typically not done every 2 years.
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A nurse is reinforcing preoperative teaching with a client of Chinese heritage who speaks limited English. Which of the following methods of communication by the nurse demonstrates cultural competence?
- A. Incorporate humor in the teaching with the client.
- B. Address the client by her last name.
- C. Maintain direct eye contact with the client.
- D. Place a hand on the client's head.
Correct Answer: B
Rationale: Addressing the client formally by her last name shows respect, which aligns with many cultural norms in Chinese heritage.
A nurse is observing a client's nonverbal behavior. When evaluating this behavior, the nurse should factor in which of the following principles that influence nonverbal communication?
- A. Nonverbal communication conveys less truth than what the client states verbally.
- B. The client's sociocultural background influences nonverbal communication.
- C. Nonverbal communication is a poor reflection of what the client feels.
- D. The client enacts nonverbal communication consciously.
Correct Answer: B
Rationale: The correct answer is B: The client's sociocultural background influences nonverbal communication. Nonverbal communication is greatly impacted by an individual's cultural norms, values, and beliefs. This influences gestures, facial expressions, posture, and personal space preferences. Understanding the client's sociocultural background helps the nurse interpret nonverbal cues accurately.
Choice A is incorrect because nonverbal communication can often convey more truth than verbal statements as it can be more spontaneous and genuine. Choice C is incorrect because nonverbal behavior can provide valuable insights into a client's true feelings and emotions. Choice D is incorrect because nonverbal communication is often unconscious and can be influenced by subconscious factors.
A nurse is planning to perform passive range of motion for a client who is immobilized. Which of the following actions should the nurse plan to take?
- A. Move body parts rapidly through the movements.
- B. Support extremities above and below joints.
- C. Stretch the body part just beyond the existing range of motion.
- D. Continue moving body parts if muscle spasticity occurs.
Correct Answer: B
Rationale: The correct answer is B: Support extremities above and below joints. This is because supporting the extremities above and below the joints helps to maintain proper alignment and stability during passive range of motion exercises, preventing injury and ensuring effective movement. Moving body parts rapidly (choice A) can cause muscle strain or injury. Stretching the body part beyond existing range (choice C) can lead to muscle or ligament damage. Continuing movement if spasticity occurs (choice D) can exacerbate muscle tightness. This is why choice B is the most appropriate action to take during passive range of motion exercises.
A nurse is collecting data about a client's cardiac functioning. The nurse auscultates an S3 sound. Which of the following causes should the nurse suspect?
- A. Atrial gallop
- B. Ventricular gallop
- C. Closing of the atrioventricular valves
- D. Closing of semilunar valves
Correct Answer: B
Rationale: The correct answer is B: Ventricular gallop. An S3 heart sound is indicative of rapid ventricular filling during diastole, which is commonly associated with heart failure. This sound occurs during the early phase of diastole when the ventricles are filled rapidly due to increased pressure in the atria. The S3 sound is heard immediately after S2 (closure of semilunar valves) when blood is rushing into the ventricles. Atrial gallop (choice A) is not associated with the S3 sound. The closing of the atrioventricular valves (choice C) is part of the normal heart sounds and does not produce an S3 sound. Similarly, the closing of semilunar valves (choice D) occurs during S2 but does not cause an S3 sound. Therefore, the correct answer is B as it directly relates to the pathophysiology of an S3 heart sound.
A nurse is collecting data from a client who has ataxia. Which of the following is appropriate to evaluate the client's ability to safely ambulate?
- A. Auscultate for Korotkoff's sounds.
- B. Perform a Romberg test.
- C. Check the function of cranial nerve V.
- D. Inspect for the presence of clubbing.
Correct Answer: B
Rationale: The correct answer is B: Perform a Romberg test. This test evaluates the client's ability to maintain balance with eyes closed, which is essential for safe ambulation in a client with ataxia. Auscultating for Korotkoff's sounds (A) is related to blood pressure assessment, not ambulation. Checking cranial nerve V function (C) is important for facial sensation and chewing, not directly related to ambulation. Inspecting for clubbing (D) is related to respiratory or cardiovascular conditions, not relevant to assessing ambulation.