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 is teaching an 86-year-old about glaucoma and how to administer eye drops. Which interventions should the nurse implement? Select all that apply.
- A. Plan the session at a time when a support person can attend
- B. Provide an environment that is private, quiet, and well lit
- C. Be detailed with the explanations to ensure understanding
- D. Engage as many of the client’s five senses as possible
- E. Give extensive written materials and a schedule to follow
Correct Answer: A;B;D
Rationale: A support person aids learning with vision issues, a private environment enhances focus, and engaging senses improves retention. Detailed explanations may overwhelm, and written materials should be concise.
The nurse is assessing the older adult client experiencing problems sleeping. Which statements, if made by the client, indicate that the client may benefit from teaching? Select all that apply.
- A. I am so tired that I need to take a nap in the middle of the day.'
- B. My routine includes a glass of warm chocolate milk at bedtime.'
- C. I installed room-darkening shades after my doctor advised these.'
- D. I’m in my bed a lot; it is the most comfortable place in my home.'
- E. I often take my pain pill for my leg pain just before going to bed.'
Correct Answer: A;B;D
Rationale: Daytime napping, chocolate milk (caffeine), and excessive bed time disrupt sleep, indicating teaching needs. Darkening shades and pain management are appropriate.
The nurse is interviewing a family member of the hospitalized 90-year-old client to assess for common problems associated with an increased risk for falling. Which questions should the nurse ask? Select all that apply.
- A. Has your mother fallen within the past year?'
- B. Has your mother had her annual influenza vaccine?'
- C. When was the last time your mother took a pain pill?'
- D. Does your mother have any problems with urination?'
- E. Does your mother have difficulty falling asleep at night?'
Correct Answer: A;C;D;E
Rationale: Questions about past falls, pain medication, urination issues, and sleep disorders assess fall risk factors. Influenza vaccine is unrelated.
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.
The nurse is assessing the chest of the normally healthy adult male client without chest abnormalities. Which chest curvature illustrated should the nurse expect to observe?
- A. Illustration A
- B. Illustration B
- C. Illustration C
- D. Illustration D
Correct Answer: C
Rationale: The normal adult chest has an anteroposterior-to-lateral ratio of approximately 1:2 and a costal angle less than 90 degrees. Illustration A is pectus excavatum, B is pectus carinatum, and D is barrel chest associated with COPD.