Nokea
Following TURP, which of the following instructions would be appropriate to prevent or alleviate anxiety concerning the client's sexual functioning?
- A. You may resumption sexual intercourse in 2 weeks.'
- B. Many men experience impotence following TURP.'
- C. A transurethral resection does not usually cause impotence.'
- D. Check with your doctor about resuming sexual activity.'
Correct Answer: C
Rationale: Although the client may experience retrograde ejaculation, it will not limit his ability to engage in sexual intercourse.
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The nurse is caring for a client with a history of a spinal cord injury who is experiencing autonomic dysreflexia. The nurse should:
- A. Place the client in a prone position
- B. Administer a vasodilator
- C. Insert a Foley catheter immediately
- D. Elevate the head of the bed
Correct Answer: C
Rationale: Autonomic dysreflexia is often triggered by bladder distension. Inserting a Foley catheter relieves the trigger. Vasodilators and positioning are secondary, and prone position is unsafe.
The client is admitted with left-sided congestive heart failure. In assessing the client for edema, the nurse should check the:
- A. Feet
- B. Neck
- C. Hands
- D. Sacrum
Correct Answer: D
Rationale: In left-sided congestive heart failure, fluid backs up into the lungs, but dependent edema is assessed in the sacrum in bedridden clients or feet in ambulatory clients. The sacrum is the most appropriate site for hospitalized clients, as they are often recumbent.
The client is diagnosed with a pneumothorax. Which finding is most expected on auscultation?
- A. Bilateral crackles
- B. Diminished breath sounds on the affected side
- C. Wheezing throughout lung fields
- D. Rhonchi in the lower lobes
Correct Answer: B
Rationale: A pneumothorax causes collapsed lung tissue, resulting in diminished or absent breath sounds on the affected side. Crackles, wheezing, and rhonchi are not typical.
Clinical manifestations seen in left-sided rather than in right-sided heart failure are:
- A. Elevated central venous pressure and peripheral edema
- B. Dyspnea and jaundice
- C. Hypotension and Hepatomegaly
- D. Decreased peripheral perfusion and rales
Correct Answer: D
Rationale: Hypothermia and azotemia are signs, but not cardinal signs, of diabetes insipidus. (A, B, C) Clinical manifestations of right-sided heart failure are weakness, peripheral edema, jugular venous distention, hepatomegaly, jaundice, and elevated central venous pressure. Clinical manifestations of left-sided heart failure are left ventricular dysfunction, decreased cardiac output, hypotension, and the backward failure as a result of increased left atrium and pulmonary artery pressures, pulmonary edema, and rales.
The nurse is teaching a client with a history of chronic kidney disease about dietary modifications. The nurse should tell the client to:
- A. Limit phosphorus intake
- B. Increase sodium intake
- C. Consume high-potassium foods
- D. Increase protein intake
Correct Answer: A
Rationale: Limiting phosphorus intake prevents bone and cardiovascular complications in chronic kidney disease.