Nokea
During a health assessment the nurse provides instructions to a client regarding the testicular self-examination (TSE). Which statement by the client indicates that the client needs further teaching regarding TSE?
- A. I know to report any small lumps.
- B. I should examine myself every 2 months.
- C. I should examine myself after I take a warm shower.
- D. I know it's normal to feel something that is cord-like in the back.
Correct Answer: B
Rationale: TSE should be performed every month. Small lumps or abnormalities should be reported. The spermatic cord finding is normal. After a warm bath or shower, the scrotum is relaxed, which makes it easier to perform TSE.
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Disulfiram has been prescribed for a client, and the nurse provides instructions to the client about the medication. Which statement by the client indicates the need for further teaching?
- A. I must be careful taking cold medicines.
- B. I will have to check my aftershave lotion.
- C. I'll be fine as long as I don't drink alcohol.
- D. I need to be careful with ingredients when I cook.
Correct Answer: C
Rationale: Clients who are taking disulfiram must be taught that substances that contain alcohol can trigger an adverse reaction. Sources of hidden alcohol include foods (soups, sauces, and vinegars), medicine (cold medicine), mouthwashes, and skin preparations (alcohol rubs and aftershave lotions).
A client has had same-day surgery to insert a ventilating tube into the tympanic membrane. Which statement assures the nurse that the client understands the discharge instructions?
- A. I will use a shower cap when taking a shower.
- B. I was told to try and avoid taking medications for pain.
- C. I need to wash my hair quickly; taking 2 minutes or less.
- D. Swimming is allowed only if I keep my head above water.
Correct Answer: A
Rationale: After the insertion of tubes into the tympanic membrane, it is important to avoid getting water in the ears. A shower cap or earplug may be used when showering if allowed by the primary health care provider. Swimming, showering without a shower cap or ear plugs, and washing the hair are avoided after surgery until the time frame designated for each is identified by the surgeon. The client should take medication as advised for postoperative discomfort.
The student nurse is listening to an orthopedic lecture on preoperative education and knee surgeries. Which statement by the student nurse indicates that the teaching has been effective?
- A. Crutch walking instructions should be scheduled before surgery.
- B. Crutch walking instructions should be given on the first postoperative day.
- C. Crutch walking instructions should be scheduled on the second postoperative day.
- D. Crutch walking instructions should be scheduled at the time of discharge after surgery.
Correct Answer: A
Rationale: It is best to assess crutch-walking ability and instruct the client with regard to the use of the crutches before surgery because this task can be difficult to learn when the client is in pain and not used to the imbalance that may occur after surgery. None of the remaining options are appropriate times to teach a client about crutch walking.
A home care nurse is instructing a mother of a child diagnosed with cystic fibrosis (CF) about the appropriate dietary measures. Which diet should the nurse tell the mother that the child needs to consume?
- A. Low-calorie, low-fat diet
- B. High-calorie, restricted fat
- C. Low-calorie, low-protein diet
- D. High-calorie, high-protein diet
Correct Answer: D
Rationale: Children with CF are managed with a high-calorie, high-protein diet. Pancreatic enzyme replacement therapy and fat-soluble vitamin supplements are administered. Fat restriction is not necessary.
The nurse is providing discharge teaching for a client diagnosed and treated for tuberculosis (TB). Which statement by the client indicates that teaching has been effective? Select all that apply.
- A. All used dishes should be sterilized.
- B. My close contacts should be tested for TB.
- C. Soiled tissues should be disposed of properly.
- D. House isolation is required for at least 8 months.
- E. The mouth should always be covered when coughing.
Correct Answer: B,C,E
Rationale: Tuberculosis is a communicable disease, and the nurse must teach the client measures to prevent its spread. Any close contacts with the client must be tested and treated if the results of the screening test are positive. Because it is an airborne disease, the client must properly dispose of used tissues and needs to cover the mouth when coughing. There is no evidence to suggest that sterilizing dishes would break the chain of infection with pulmonary TB. It is not necessary for the client to isolate herself or himself to the house. Once the client is treated and results of three sputum cultures are negative, the client will not spread the infection.