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A nurse is reinforcing teaching with a client about breast self-examinations. Which of the following statements by the client indicates an understanding of the teaching?
- A. It is common for the skin on my breasts to dimple.
- B. I will perform breast exams every other month.
- C. It is common for one breast to be larger than the other.
- D. I will perform breast exams the day my period begins.
Correct Answer: C
Rationale: It is normal for one breast to be slightly larger than the other, and this statement reflects an understanding of breast self-examination teaching.
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A nurse is reinforcing discharge teaching for a client who had a cerebrovascular accident (CVA) and requires assistance to perform their ADLs. Which of the following statements should the nurse provide?
- A. Plan to hire a home care aid to perform all of your ADLs.
- B. You will not become fatigued when you use assistive devices.
- C. Install grab bars in your shower to assist with your balance.
- D. Place a towel in the shower to prevent slipping.
Correct Answer: C
Rationale: Installing grab bars enhances safety and supports independence in ADLs post-CVA, addressing balance issues.
A nurse is contributing to the plan of care for a client following a total hip arthroplasty. Which of the following interventions should the nurse recommend?
- A. Turn the client every 4 hr for 48 hr while on bed rest.
- B. Have the client use an incentive spirometer every 4 hr.
- C. Instruct the client to bend from the hip when retrieving items from the floor.
- D. Maintain hip abduction when turning the client.
Correct Answer: D
Rationale: Maintaining hip abduction prevents dislocation of the new hip joint, a critical consideration post-hip arthroplasty.
A nurse is assisting with the care of an 18-year-old client who is at their provider's office for an annual physical. The client inquires about cancer examinations that they should have. Which of the following examinations should the nurse recommend?
- A. Testicular
- B. Skin
- C. Prostate
- D. Colorectal
Correct Answer: A
Rationale: Testicular self-examination is recommended for young males (e.g., 18-year-olds) to detect early signs of testicular cancer.
A nurse is reinforcing teaching with a client who is to take a fecal occult blood test at home. Which of the following instructions should the nurse include in the teaching?
- A. Apply five drops of developer to each smear.
- B. Use the same part of stool for each sample.
- C. Ensure the sample contains no urine.
- D. Wait 10 min before applying the developing solution.
Correct Answer: C
Rationale: Ensuring the sample is free of urine prevents contamination, which could lead to inaccurate fecal occult blood test results.
A nurse at an urgent care clinic is contributing to the plan of care for a client following a near drowning while attempting to walk across a frozen pond. Which of the following interventions should the nurse recommend?
- A. Replace wet clothing with warmed blankets.
- B. Use an axillary thermometer to monitor the client's temperature.
- C. Assist the client to perform range-of-motion exercises.
- D. Administer an antihypertensive medication.
Correct Answer: A
Rationale: Replacing wet clothing with warmed blankets prevents hypothermia, a critical risk after a near-drowning incident.