Nokea
A nurse is reinforcing teaching with a client who has fibrocystic breast changes about dietary changes that can help minimize symptoms. Which of the following dietary elements should the nurse instruct the client to limit?
- A. Fat
- B. Water
- C. Calcium
- D. Vitamin E
Correct Answer: A
Rationale: A diet low in fat has been shown to help reduce fibrocystic breast pain and discomfort.
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A nurse is collecting data from a client who is 2 days postoperative. The nurse auscultates bilateral breath sounds but absent breath sounds in the bases. The nurse should suspect which of the following postoperative complications?
- A. Atelectasis
- B. Rales
- C. Rhonchi
- D. Pneumothorax
Correct Answer: A
Rationale: Atelectasis causes absent breath sounds in lung bases due to alveolar collapse.
A nurse is collecting data from a client who has respiratory insufficiency. Which of the following findings should the nurse identify as an early sign of inadequate oxygenation?
- A. Diaphoresis
- B. Retractions
- C. Cyanosis
- D. Restlessness
Correct Answer: D
Rationale: Restlessness is an early sign of inadequate oxygenation, indicating the body's attempt to compensate for low oxygen levels.
A nurse is collecting data from a client who sustained blood loss. Which of the following findings should the nurse identify as a manifestation of hypovolemia?
- A. Decreased heart rate
- B. Dyspnea
- C. Increased blood pressure
- D. Thready pulse
Correct Answer: D
Rationale: The correct answer is D: Thready pulse. Hypovolemia, or low blood volume, leads to decreased blood flow, resulting in a thready pulse due to decreased stroke volume. A: Decreased heart rate is not typically associated with hypovolemia as the body may try to compensate by increasing heart rate. B: Dyspnea may occur in hypovolemic shock, but it is not a specific manifestation of hypovolemia. C: Increased blood pressure is not a typical finding in hypovolemia, as the blood pressure tends to drop due to decreased fluid volume. Thus, D is the correct choice as it directly correlates with the pathophysiology of hypovolemia.
A nurse is emptying a client's urinal when she notices the urine is dark amber, cloudy, and has an unpleasant odor. The nurse should identify that these findings are likely to be the result of which of the following?
- A. Urinary tract infection
- B. Urinary incontinence
- C. Urinary frequency
- D. Urinary retention
Correct Answer: A
Rationale: The correct answer is A: Urinary tract infection. The dark amber color, cloudy appearance, and unpleasant odor of the urine indicate a possible infection. Dark amber color suggests concentrated urine due to dehydration, common in UTIs. Cloudiness indicates presence of bacteria or pus, typical in UTIs. Unpleasant odor is often caused by bacteria breaking down urine. Choices B, C, and D are unlikely to cause these specific findings. Urinary incontinence refers to involuntary leakage of urine and does not directly affect urine appearance. Urinary frequency means urinating more often but doesn't typically change urine color or odor. Urinary retention is the inability to empty the bladder completely, which may lead to overflow incontinence, but doesn't directly cause dark amber, cloudy, and foul-smelling urine.
A nurse at a community health clinic is assisting with creating a brochure about testicular cancer. Which of the following information should the nurse include?
- A. Perform a testicular self-examination twice per year.
- B. Palpate the epididymis.
- C. Gently roll the testicles to feel for abnormalities.
- D. Use one hand to palpate the testicles.
Correct Answer: C
Rationale: The correct answer is C: Gently roll the testicles to feel for abnormalities. This is the most appropriate information to include in the brochure because gently rolling the testicles between the thumb and fingers is the recommended technique for testicular self-examination. By rolling the testicles, individuals can better detect any lumps or changes in texture that may indicate testicular cancer.
Choice A is incorrect because the current recommendation is to perform testicular self-exams monthly, not twice per year. Choice B is incorrect as palpating the epididymis is not part of the standard testicular self-examination procedure. Choice D is incorrect because using both hands is recommended for better examination.