Nokea
A nurse is teaching self-management to a client who has hepatitis B. Which of the following instructions should the nurse include in the teaching?
- A. Limit salt intake.
- B. Avoid consuming alcohol.
- C. Engage in light exercise regularly.
- D. Rest frequently throughout the day.
Correct Answer: D
Rationale: The correct answer is D: Rest frequently throughout the day. For a client with hepatitis B, rest is essential to allow the body to recover and heal. Hepatitis B can cause fatigue and weakness, so resting frequently helps to conserve energy and support the immune system in fighting the infection. Limiting salt intake (Choice A) is not directly related to managing hepatitis B. Avoiding alcohol (Choice B) is important but more for liver health in general, not specifically for hepatitis B. Engaging in light exercise regularly (Choice C) may be beneficial for overall health, but during active hepatitis B infection, rest is more crucial.
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A nurse in a clinic is interviewing a client who has a possible diagnosis of endometriosis. Which of the following findings in the client's history should the nurse recognize as consistent with a diagnosis of endometriosis?
- A. Dysmenorrhea that is unresponsive to NSAIDs
- B. Heavy menstrual bleeding
- C. Positive family history of fibroids
- D. Pelvic pain after intercourse
Correct Answer: A
Rationale: The correct answer is A: Dysmenorrhea that is unresponsive to NSAIDs. Endometriosis is characterized by severe menstrual pain that is not relieved by NSAIDs. This is due to the abnormal growth of endometrial tissue outside the uterus. Heavy menstrual bleeding (B) is a common symptom but not specific to endometriosis. Positive family history of fibroids (C) is unrelated to endometriosis. Pelvic pain after intercourse (D) can be a symptom of endometriosis but is not as specific as unresponsive dysmenorrhea.
A nurse is providing discharge teaching to a client who has a new arteriovenous fistula in the right forearm. Which of the following manifestations should the nurse include in the teaching as a possible indication of venous insufficiency?
- A. Cold and numbness distal to the fistula site
- B. Swelling around the fistula
- C. Bleeding from the fistula
- D. Pain at the site of fistula
Correct Answer: A
Rationale: The correct answer is A: Cold and numbness distal to the fistula site. This is indicative of venous insufficiency, which can occur when the arteriovenous fistula is not functioning properly. When there is inadequate blood flow through the fistula, it can result in reduced circulation to the distal part of the arm, leading to coldness and numbness. Swelling around the fistula (choice B) is more commonly associated with infection or inadequate drainage. Bleeding from the fistula (choice C) is a potential complication but not a typical manifestation of venous insufficiency. Pain at the site of the fistula (choice D) may indicate infection or clotting issues rather than venous insufficiency.
A nurse is assessing a client who reports numbness and pain in his right palm, index finger, and middle finger. The client reports working with a keyboard most of the time while at work. The nurse suspects carpal tunnel syndrome. Which of the following tests should the nurse request that the client perform?
- A. Hold the wrist at a 90-degree flexion.
- B. Perform a straight leg raise test.
- C. Tap the wrist for tenderness.
- D. Hold the arm in an elevated position.
Correct Answer: A
Rationale: The correct answer is A: Hold the wrist at a 90-degree flexion. This test, known as the Phalen's test, is used to assess for carpal tunnel syndrome. By holding the wrist in a flexed position for about 60 seconds, the test can reproduce symptoms of numbness and tingling in the affected fingers. This occurs due to increased pressure on the median nerve, which is characteristic of carpal tunnel syndrome.
Choices B, C, and D are incorrect:
B: Performing a straight leg raise test is used to assess for sciatic nerve irritation in the lower back, not carpal tunnel syndrome.
C: Tapping the wrist for tenderness is not a specific test for carpal tunnel syndrome.
D: Holding the arm in an elevated position is not a recognized test for carpal tunnel syndrome and would not provide relevant information in this context.
A nurse is reviewing the laboratory values of a client who had a myocardial infarction 3 hr ago. The nurse should expect which of the following laboratory values to be elevated?
- A. Serum sodium
- B. Serum glucose
- C. Troponin I
- D. White blood cell count
Correct Answer: C
Rationale: The correct answer is C: Troponin I. Troponin I is a specific marker for myocardial damage. After a myocardial infarction, the damaged heart muscle releases troponin I into the bloodstream, leading to elevated levels. This helps in diagnosing and monitoring the extent of myocardial damage.
A: Serum sodium levels are not typically affected by a myocardial infarction.
B: Serum glucose levels may be elevated due to stress response but are not specific to myocardial infarction.
D: White blood cell count may be elevated in response to inflammation caused by myocardial infarction, but it is not as specific as troponin I.
A nurse in a clinic is teaching information about cervical polyps with a client who has a new diagnosis. Which of the following information should the nurse include in the teaching?
- A. Postcoital bleeding may occur.
- B. A pelvic ultrasound is required for diagnosis.
- C. Cervical polyps usually resolve without treatment.
- D. Cervical polyps are rarely associated with cancer.
Correct Answer: A
Rationale: The correct answer is A: Postcoital bleeding may occur. This information is essential to include in teaching about cervical polyps because it is a common symptom associated with this condition. Cervical polyps are benign growths on the cervix that can cause bleeding, especially after intercourse. It is crucial for the client to be aware of this symptom to monitor for any abnormal bleeding and seek medical attention if necessary.
Option B is incorrect because a pelvic ultrasound is not always required for diagnosing cervical polyps; they can often be diagnosed through a pelvic exam. Option C is incorrect because not all cervical polyps resolve on their own and may require treatment if symptomatic. Option D is incorrect because while cervical polyps are usually benign, they can be associated with an increased risk of cervical cancer in some cases.