Nokea
The client diagnosed with cancer of the uterus is scheduled to have radiation brachytherapy. Which precautions should the nurse implement? Select all that apply.
- A. Place the client in a private room.
- B. Wear a dosimeter when entering the room.
- C. Encourage visitors to come and stay with the client.
- D. Plan to spend extended time with the client.
- E. Notify the nuclear medicine technician.
Correct Answer: A,B
Rationale: Brachytherapy requires a private room and dosimeter use to minimize radiation exposure. Visitors are limited, extended nurse time is avoided, and nuclear medicine notification is unnecessary.
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The nurse correctly informs the client that the breast self-examination (BSE) technique involves palpating each breast moving in small concentric circles, following imaginary spokes in a wheel, or moving in rows from superior to inferior stress of the breast. Besides the breast, which other body area is essential to palpate?
- A. The axillae
- B. The sternum
- C. The clavicles
- D. The ribs
Correct Answer: A
Rationale: The axillae (armpits) contain lymph nodes that drain the breast tissue, and palpating this area is essential to detect any abnormal lymph node enlargement, which could indicate breast pathology.
The client has an infected Bartholin’s cyst and the HCP has performed an incision and drainage (I&D) of the area. Which discharge instructions should the nurse teach the client?
- A. Complete all antibiotics as ordered.
- B. Report any drainage immediately.
- C. Keep all water away from the area.
- D. Lie prone as much as possible.
Correct Answer: A
Rationale: Completing antibiotics prevents recurrence of infection post-I&D. Drainage is expected, water avoidance is impractical, and prone positioning is unnecessary.
What intervention should the nurse implement for a client diagnosed with a rectocele?
- A. Limit oral intake to decrease voiding.
- B. Encourage a low-residue diet.
- C. Administer a stool softener daily.
- D. Arrange for the client to take sitz baths.
Correct Answer: C
Rationale: Stool softeners prevent straining during bowel movements, reducing rectocele pressure. Limiting intake is inappropriate, low-residue diets increase constipation risk, and sitz baths are less specific.
The male client is considering a vasectomy for birth control. Which information should the nurse teach the client?
- A. Instruct the client to use hot packs to relieve scrotal edema after the surgery.
- B. Tell the client to wear loose-fitting boxer underwear after the surgery.
- C. Explain initially an alternate form of birth control will be required.
- D. Discuss potency will be diminished about 20% after a vasectomy.
Correct Answer: C
Rationale: Alternate contraception is needed post-vasectomy until sperm clearance (confirmed by semen analysis). Hot packs worsen edema, boxer underwear is nonspecific, and potency is unaffected.
The nurse is caring for a young adult client who has been diagnosed with gonorrhea. Which statement reflects an understanding of the transmission of sexually transmitted diseases?
- A. Only lower socioeconomic income people are at risk for gonorrhea and syphilis.
- B. The longer a client waits to become sexually active, the greater the risk for an STD.
- C. Females can transmit infectious diseases more rapidly than males.
- D. If a client is diagnosed with an STD, the client should be evaluated for other STDs.
Correct Answer: D
Rationale: STD diagnosis warrants screening for co-infections (e.g., chlamydia, HIV) due to shared risk behaviors. Socioeconomic status, delayed sexual activity, and gender transmission rates are misconceptions.