Nokea
The client is diagnosed with benign uterine fibroid tumors. Which question should the nurse ask to determine if the client is experiencing a complication?
- A. How many periods have you missed?'
- B. Do you get short of breath easily?'
- C. How many times have you been pregnant?'
- D. Where is the location of the pain you are having?'
Correct Answer: D
Rationale: Pain location helps identify complications like fibroid degeneration or pressure on organs. Missed periods are common, shortness of breath is unrelated, and pregnancy history is less relevant.
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Unless the physician specifies otherwise, what is the maximum volume of urine the nurse should remove with the catheter at this time?
- A. 500 mL
- B. 1,000 mL
- C. 1,500 mL
- D. 2,000 mL
Correct Answer: B
Rationale: Removing up to 1,000 mL prevents bladder decompression injury, balancing the need to relieve retention with the risk of hypotension or hematuria.
The 30-year-old male client diagnosed with germinal cell carcinoma of the testes asks the nurse, 'What chance do I have? Should I end it all now?' Which response by the nurse indicates an understanding of the disease process?
- A. God does not want you to give up hope and end it all now.'
- B. There is a good chance for survival with standard treatment options.'
- C. There may be little hope, but ending it all is not the answer.'
- D. You have a 50/50 chance of living for at least 5 years.'
Correct Answer: B
Rationale: Germinal cell carcinoma has a high cure rate with treatment (e.g., orchiectomy, chemotherapy), offering good survival chances. Religious references, pessimism, or vague statistics are less appropriate.
On the basis of this client's age, which statement by the nurse is the best explanation for the client's discomfort?
- A. The pelvic muscles are more sensitive to pressure after menopause.
- B. The clitoris is unable to respond to sexual foreplay as women age.
- C. The vagina hypertrophies if intercourse is infrequent.
- D. The mucus-producing glands decrease with aging.
Correct Answer: D
Rationale: Postmenopausal vaginal dryness due to decreased mucus production is a common cause of painful intercourse in older women.
The nurse is formulating a care plan for a client post-abdominal hysterectomy. Which nursing diagnosis is appropriate for the client who has developed a complication?
- A. Potential for urinary retention.
- B. Potential for nerve damage.
- C. Potential for intestinal obstruction.
- D. Potential for fluid imbalance.
Correct Answer: C
Rationale: Intestinal obstruction is a common complication post-abdominal hysterectomy due to adhesions or ileus. Urinary retention and fluid imbalance are risks but less specific, and nerve damage is rare.
To accurately determine the dosage of antineoplastic drugs, which information is essential to obtain from the client's chart?
- A. Urine output for the past 24 hours
- B. Body weight and height
- C. Date of surgery
- D. Drug allergies
Correct Answer: B
Rationale: Body weight and height are used to calculate body surface area, which determines accurate dosing of antineoplastic drugs.