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The client is diagnosed with left mastitis. Which assessment findings should the nurse observe?
- A. Dimpling of the left breast when the client raises the arm.
- B. A round lump in the left breast that is tender during menses.
- C. A dull pain in the left breast and tough, doughy feeling skin.
- D. Bloody discharge from the nipple and a hard palpable mass.
Correct Answer: C
Rationale: Mastitis causes dull pain and tough, doughy skin due to inflammation. Dimpling suggests cancer, cyclical lumps are fibrocystic, and bloody discharge/mass indicates malignancy.
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The nurse and an unlicensed assistive personnel (UAP) are caring for clients on a genitourinary floor. Which nursing task can be delegated to the UAP?
- A. Increase the drip rate on the Murphy drip irrigation set.
- B. Check the suprapubic catheter insertion site for infection.
- C. Encourage the two (2)-hour postoperative client to turn and cough.
- D. Document the amount of red drainage in the catheter.
Correct Answer: C
Rationale: Encouraging turning and coughing is within UAP scope to prevent respiratory complications. Adjusting irrigation, checking for infection, and documenting drainage require nursing judgment.
Which vaccination should the nurse recommend to the postpubertal male to prevent orchitis?
- A. Yearly flu injections.
- B. Herpes varicella inoculations.
- C. Mumps vaccination.
- D. Rubella injections.
Correct Answer: C
Rationale: Mumps vaccination prevents mumps-related orchitis, a common cause in postpubertal males. Flu, varicella, and rubella are unrelated to orchitis.
The nurse is assessing a male client for symptoms of gonorrhea. Which data support the diagnosis?
- A. Presence of a chancre sore on the penis.
- B. No symptoms.
- C. A CD4 count of less than 200.
- D. Pain in the testes and scrotal edema.
Correct Answer: B
Rationale: Gonorrhea in males can be asymptomatic, especially early. Chancre sores indicate syphilis, low CD4 is HIV-related, and testicular pain/edema suggest epididymitis, not gonorrhea.
The nurse is teaching a class on breast health to a group of ladies at a senior citizen's center. Which risk factor is the most important to emphasize to this group?
- A. The clients should find out about their family history of breast cancer.
- B. Men at this age can get breast cancer also and should be screened.
- C. Monthly breast self-examination is the key to early detection.
- D. The older a woman gets, the greater the chance of developing breast cancer.
Correct Answer: D
Rationale: Age is the most significant risk factor for breast cancer, with risk increasing as women age, especially in seniors. Family history is important but less universal, male breast cancer is rare, and BSE is secondary to awareness and screening.
The nurse is preparing the care plan for a 45-year-old client who has had a radical prostatectomy. Which psychosocial and physiological problem should be included in the plan?
- A. Altered coping.
- B. High risk for hemorrhage.
- C. Sexual impotence.
- D. Risk for electrolyte imbalance.
Correct Answer: C
Rationale: Sexual impotence is a common issue post-radical prostatectomy due to nerve damage, impacting psychosocial and physiological well-being. Coping, hemorrhage, and electrolyte imbalance are less specific.