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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, reflecting an understanding of breast self-examination teaching.
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A nurse is admitting a client who reports excessive thirst, fever, and periods of confusion. The nurse suspects the client is experiencing heat exhaustion. Which of the following electrolyte imbalances should the nurse expect?
- A. Hypernatremia
- B. Hypocalcemia
- C. Hyperkalemia
- D. Hyperphosphatemia
Correct Answer: A
Rationale: Heat exhaustion can lead to excessive sweating and dehydration, causing hypernatremia (elevated sodium levels) due to water loss.
A nurse is reinforcing teaching with a 30-year-old client who is concerned about cervical cancer. Which of the following statements should the nurse make?
- A. Cervical cancer screenings should begin at age 40
- B. Plan to continue cervical cancer screenings for the rest of your life.
- C. You should get a Papanicolaou (Pap) test and human papillomavirus test every 5 years.
- D. If you are immunized against human papillomavirus, you don't need cervical cancer screenings.
Correct Answer: C
Rationale: For a 30-year-old, Pap and HPV testing every 5 years is recommended per current guidelines, making this the correct statement.
A nurse is reinforcing teaching about meal planning with a client who has hypertension. Which of the following statements by the client indicates an understanding of the teaching?
- A. I can season food with ketchup.
- B. I can season food with vinegar.
- C. I can have a bologna sandwich
- D. I can have canned soup.
Correct Answer: B
Rationale: Vinegar is low in sodium, unlike ketchup, bologna, or canned soup, aligning with hypertension dietary teaching.
A nurse is caring for a client who is postoperative. For which of the following findings should the nurse suspect the client is experiencing a deep-vein thrombosis?
- A. Muscle spasms
- B. Absent pedal pulse
- C. Numbness of the affected extremity
- D. Warmth of the affected extremity
Correct Answer: D
Rationale: Warmth is a classic sign of deep-vein thrombosis due to inflammation and blood flow changes in the affected area.
A nurse is assisting with the care of a client who had a bronchoscopy 12 hr ago. Which of the following findings should the nurse report to the provider?
- A. The client has inspiratory stridor
- B. The client reports a sore throat.
- C. The client's sputum has streaks of blood.
- D. The client's temperature is 38.6°C / 101.4°F
Correct Answer: A
Rationale: Inspiratory stridor indicates possible airway obstruction or swelling post-bronchoscopy, a serious complication requiring immediate reporting.