Nokea
Nurse in clinic caring for 21 yo client who reports sore throat. Client tells nurse he hasn't seen a doctor since high school. Which health screening should nurse expect provider to perform for this client?
- A. Testicular exam
- B. Blood glucose
- C. Fecal occult blood
- D. Prostate-specific antigen
Correct Answer: A
Rationale: The correct answer is A: Testicular exam. The nurse should expect the provider to perform a testicular exam because the client is a 21-year-old male. Testicular cancer is most common in young men, with the highest incidence between ages 15-35. Since the client has not had a doctor visit since high school, it is important to screen for testicular cancer as part of routine health maintenance. This exam can help detect any abnormalities early on, leading to better outcomes. Blood glucose (choice B) screening is more relevant for diabetes, which typically affects older individuals. Fecal occult blood (choice C) screening is used for detecting colorectal cancer, typically recommended for individuals over 50. Prostate-specific antigen (choice D) screening is for prostate cancer, which is more common in older men.
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A mother tells nurse that her 2 yo has temper tantrums. Child says 'no' every time mother tries to help her get dressed. Nurse explains that developmentally the toddler is...
- A. Trying to gain her independence
- B. Developing sense of trust
- C. Manifesting anger management problem
- D. Attempting to finish a project she started
Correct Answer: A
Rationale: The correct answer is A: Trying to gain her independence. At age 2, children often exhibit behaviors to assert their independence. By saying 'no' and resisting help with dressing, the toddler is showing a desire to do things on her own and asserting her autonomy. This behavior aligns with the typical developmental stage of toddlers seeking independence and autonomy. Choices B, C, and D are incorrect because they do not align with the typical behaviors and developmental milestones of a 2-year-old. Choice B (Developing sense of trust) is more characteristic of infancy, choice C (Manifesting anger management problem) is not appropriate for a toddler's behavior in this context, and choice D (Attempting to finish a project she started) does not reflect the developmental stage of a 2-year-old.
Nurse on med-surg unit is informed that mass casualty event occurred & it's necessary to discharge clients to make beds available for injury victims. Which clients can be safely discharged? (Select all that apply.)
- A. Client who's dehydrated & receiving IV fluid/electrolytes
- B. Client with NG tube to treat small bowel obstruction
- C. Client who's scheduled for TURP (prostate resection)
- D. Client who is 24h post-op after mastectomy
- E. Client scheduled for appendectomy
Correct Answer: C,D
Rationale: Correct Answer: C, D
Rationale:
1. Client scheduled for TURP (prostate resection): This client can be safely discharged as the procedure is elective and not urgent.
2. Client who is 24h post-op after mastectomy: This client is stable post-operation and can be discharged with appropriate follow-up care.
Summary of other choices:
A: Client who's dehydrated & receiving IV fluid/electrolytes - This client needs continued treatment and monitoring.
B: Client with NG tube to treat small bowel obstruction - This client requires ongoing treatment and observation.
E: Client scheduled for appendectomy - This client needs urgent surgical intervention and cannot be safely discharged.
Nurse is caring for a client who presents with linear clusters of fluid-containing vesicles with some crusting. Which should the nurse suspect?
- A. Allergic reaction
- B. Ringworm
- C. Systemic lupus erythematosus
- D. Herpes zoster
Correct Answer: D
Rationale: The correct answer is D: Herpes zoster. The presentation of linear clusters of fluid-containing vesicles with crusting is characteristic of herpes zoster, also known as shingles. This is caused by the reactivation of the varicella-zoster virus, which initially causes chickenpox. The linear distribution along a dermatome is a key feature distinguishing it from other conditions. Allergic reaction (A) typically presents with hives or erythema, not vesicles. Ringworm (B) presents with a circular, scaly rash. Systemic lupus erythematosus (C) is an autoimmune disease with a different presentation.
Nurse talking with parents of 6 mo infant about gross motor development. Which gross motor skills are expected in next 3 mo? (Select all that apply.)
- A. Rolls from back to front
- B. Bears weight on legs
- C. Walks holding onto furniture
- D. Sits unsupported
- E. Sits down from standing position
Correct Answer: A,B,D
Rationale: The correct answer is A, B, and D. By 9 months, infants typically develop the ability to roll from back to front (choice A), bear weight on legs (choice B), and sit unsupported (choice D). Rolling from back to front demonstrates improved core strength and coordination. Bearing weight on legs indicates developing leg muscles and balance. Sitting unsupported signifies improved trunk control and balance. Choices C and E involve more advanced skills typically seen around 9-12 months. Choice C, walking holding onto furniture, is usually seen around 10-12 months, and choice E, sitting down from a standing position, typically emerges around 9-12 months.
Nurse is counseling older adult who describes having difficulty with several issues. Which problem should nurse identify as priority for more assessment & intervention?
- A. "I spent my whole life dreaming about retirement
- B. & now I wish I had my job back"
- C. It's been so stressful for me to have to depend on my son to help around the house
- D. I just heard my friend Al died. That's the 3rd one in 3 months.
- E. I'm struggling with helping out in my community. I just don't know what I can do.
Correct Answer: D
Rationale: The correct answer is D. The nurse should prioritize assessing and intervening in the older adult's grief over losing friends. This is crucial as multiple recent losses can lead to increased risk of depression and isolation. It is essential to address feelings of loss and provide support. Choice A focuses on retirement dreams, which may not be as urgent. Choice B indicates job-related regret. Choice C mentions stress from dependence on son. These issues are important but do not pose immediate risks to mental health and well-being compared to dealing with multiple recent deaths. Choices E, F, and G do not provide relevant information to prioritize over grief from recent losses.