Nokea
The 32-year-old has been trying to get pregnant for the past 10 years- The client consults a family planning clinic after being unsuccessful with the calendar and basal body temperature methods in determining the time of ovulation. Which statement by the nurse would be most appropriate?
- A. Let me review the methods with you; maybe you have not been using them correctly.'
- B. Have you considered that you might not be ovulating and that adoption is an option?'
- C. Test kits are available that will detect an enzyme in cervical mucus that signals ovulation.'
- D. If your spouse wears restrictive underwear, this can reduce your chance of conception.'
Correct Answer: C
Rationale: Suggesting an ovulation test kit, which detects guaiacol peroxidase in cervical mucus to signal ovulation, is most appropriate after 10 years of unsuccessful methods. Reviewing methods is less helpful, adoption is premature, and male underwear addresses sperm count, not ovulation timing.
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The nurse educator is planning teaching for other nurses after noting that some nurses need additional education on insulin types and how to use the new insulin injection pens. When planning teaching, which question by the educator best reflects consideration that the nurses are adult learners?
- A. Does anyone want to volunteer to prepare a poster board and help with handouts?'
- B. What do you need to learn about insulin, and what teaching method would you prefer?'
- C. Can you attend a presentation if I post various times during the day and evening shift?'
- D. What don’t you understand about the information in the policy and procedure manual?'
Correct Answer: B
Rationale: Adult learners are independent and benefit from identifying their own learning needs and preferred methods. Asking about specific needs and teaching preferences supports this, unlike posters, presentations, or implying misunderstanding.
The nurse is caring for the 50-year-old client who reports having difficulty falling asleep. Which recommendations should the nurse make to this client? Select all that apply.
- A. Drink a glass of wine or a beer before bedtime
- B. Avoid exercising 2 to 3 hours before bedtime
- C. Go to bed at the same time each night
- D. Watch television in bed just before bedtime
- E. Avoid eating large or spicy meals in the evening
Correct Answer: B;C;E
Rationale: Avoiding exercise near bedtime, maintaining a consistent bedtime, and avoiding large/spicy meals promote sleep. Alcohol and TV in bed can disrupt sleep.
The nurse is assessing the older adult. Which tool should the nurse select to identify the client’s needs and care deficits?
- A. Katz Index of Activities of Daily Living
- B. Maslow’s Hierarchy of Needs
- C. Mini Mental State Exam (MMSE)
- D. Erikson’s Developmental Tasks
Correct Answer: A
Rationale: The Katz Index assesses functional ability in daily activities, identifying care deficits. Maslow’s is a general needs theory, MMSE assesses cognition, and Erikson’s is developmental.
The 50-year-old asks the nurse how to calculate BM]. The client weighs 134 1b and is 5’3” tall. Together, the client and nurse calculate the client’s BMI rounded to the nearest tenth. What is the client’s BMI?
Correct Answer: 23.8
Rationale: BMI = [weight (lb) / height (in)²] × 703 = [134 / (63)²] × 703 = [134 / 3969] × 703 ≈ 23.75, rounded to 23.8.
The nurse is evaluating the older adult client’s hydration status. Which information should the nurse include? Select all that apply.
- A. Urine color
- B. Serum blood urea nitrogen (BUN) and creatinine
- C. Serum white blood cell (WBC) and differential count
- D. Urine specific gravity
- E. 24-hour fluid intake and urine output
Correct Answer: A;B;D;E
Rationale: Urine color, BUN/creatinine, specific gravity, and 24-hour intake/output assess hydration. WBC count evaluates infection, not hydration.