Nokea
Because the client is receiving this type of radiation therapy, which nursing interventions should the nurse include in the care plan? Select all that apply.
- A. Keep the client on strict bed rest.
- B. Limit the amount of time visitors stay with the client.
- C. Place urine and feces in a closed container.
- D. Weigh the client daily before breakfast.
- E. Stand at a distance and talk with the client from the doorway.
- F. Spend as little time as possible with the client.
Correct Answer: A,B,E,F
Rationale: Strict bed rest prevents dislodging the implant, limiting visitor time and nurse exposure reduces radiation risk, and standing at a distance minimizes exposure.
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Which nursing order is most appropriate to add to the client's initial postoperative care plan?
- A. Connect the cystostomy tube to a leg bag for drainage.
- B. Secure the cystostomy tube to the client's thigh.
- C. Ensure that the cystostomy tube is unclamped at all times.
- D. Clamp the indwelling catheter when the cystostomy tube is irrigated.
Correct Answer: C
Rationale: Keeping the cystostomy tube unclamped ensures continuous drainage, preventing complications like infection or pressure buildup.
Which vaccination should the nurse recommend to the postpubertal male to prevent orchitis?
- A. Yearly flu injections.
- B. Herpes varicella inoculations.
- C. Mumps vaccination.
- D. Rubella injections.
Correct Answer: C
Rationale: Mumps vaccination prevents mumps-related orchitis, a common cause in postpubertal males. Flu, varicella, and rubella are unrelated to orchitis.
If the client tells the nurse that she would prefer to postpone the mastectomy until the biopsy has been more thoroughly examined, which is the most appropriate initial nursing action?
- A. Explain that most biopsies are accurate.
- B. Advocate for her choice of treatment.
- C. Discourage her from opposing the physician.
- D. Recommend that she seek a second opinion.
Correct Answer: B
Rationale: Advocating for the client's preferences supports patient autonomy and ensures her concerns are addressed, aligning with patient-centered care principles.
The nurse is teaching a class to older women concerning cancer of the uterus. Which situation is a risk factor for developing endometrial cancer?
- A. Age 40 years or younger.
- B. Perimenopausal bleeding.
- C. Progesterone given with estrogen.
- D. Truncal obesity.
Correct Answer: D
Rationale: Truncal obesity increases estrogen levels, a major risk for endometrial cancer. Young age, perimenopausal bleeding, and progesterone with estrogen are not primary risks.
The nurse is assessing a male client for symptoms of gonorrhea. Which data support the diagnosis?
- A. Presence of a chancre sore on the penis.
- B. No symptoms.
- C. A CD4 count of less than 200.
- D. Pain in the testes and scrotal edema.
Correct Answer: B
Rationale: Gonorrhea in males can be asymptomatic, especially early. Chancre sores indicate syphilis, low CD4 is HIV-related, and testicular pain/edema suggest epididymitis, not gonorrhea.