Nokea
The client receives zidovudine (Retrovir) for treatment of HIV infection. Which assessment data indicates an adverse reaction to the drug?
- A. Cough
- B. Enlarged lymph nodes
- C. Decreased WBC count
- D. Fever
Correct Answer: C
Rationale: The correct answer is C: Decreased WBC count. Zidovudine is known to cause bone marrow suppression which can lead to a decrease in white blood cell count. This is an adverse reaction as it increases the risk of infections.
A: Cough is not a common adverse reaction to zidovudine.
B: Enlarged lymph nodes are not directly associated with zidovudine adverse reactions.
D: Fever is a non-specific symptom and can occur due to various reasons, not specifically related to zidovudine.
Therefore, the most concerning and relevant assessment data indicating an adverse reaction to zidovudine is a decreased white blood cell count.
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The nurse is discussing risk factors for endometriosis with a new nurse. Which client would the nurse identify as being at the highest risk for developing endometriosis?
- A. One who smokes one pack per day
- B. One who states her menstrual cycles are irregular
- C. One who states her mother had endometriosis
- D. One who had a previous cesarean section
Correct Answer: C
Rationale: The correct answer is C because genetics play a significant role in the development of endometriosis. If a client's mother had endometriosis, there is an increased likelihood of her developing the condition. This is due to shared genetic factors that may predispose individuals to endometriosis. Smoking (choice A) is a risk factor for many health conditions but not specifically for endometriosis. Irregular menstrual cycles (choice B) may be a symptom of endometriosis but do not directly increase the risk of developing it. Having a previous cesarean section (choice D) is not a known risk factor for endometriosis.
During the physical assessment of a female client with HPV, which should the nurse expect to find?
- A. Purulent vaginal discharge
- B. Condylomata
- C. Malodorous vaginal discharge
- D. No clinical manifestation
Correct Answer: B
Rationale: The correct answer is B: Condylomata. HPV can manifest as genital warts or condylomata acuminata. These are flesh-colored growths that appear on the genital area. The presence of condylomata indicates an active HPV infection. Choices A and C are incorrect as purulent or malodorous discharge is not typically associated with HPV. Choice D is incorrect as HPV often presents with visible symptoms like condylomata.
A nurse is providing preoperative teaching for a woman who is undergoing a total mastectomy. Which will this teaching include? Select all that apply.
- A. Explain that she will have an IV, a drain, and a dressing in place on awakening. Tell her about expectations she may have regarding physical appearance, pain management, equipment that will be used (IVs, drains, etc.).
- B. Explain that she will be provided pain management as needed; monitor and review the pain scale to be used to identify level of intensity.
- C. Have her elevate the affected arm with pillows.
- D. Turn the woman every 4 hours, alternating between the unaffected side and affected side. To prevent pneumonia and complications, have her cough and take deep breaths every 2 hours, while nurse applies support to the chest.
Correct Answer: C
Rationale: Rationale for Answer C (Correct Answer):
1. Elevating the affected arm with pillows post-mastectomy helps reduce swelling and promote lymphatic drainage, aiding in preventing lymphedema.
2. By elevating the arm, it reduces strain on the surgical site and surrounding tissues, promoting comfort and aiding in the healing process.
3. This positioning also helps in preventing postoperative complications such as shoulder stiffness and contractures.
Summary of Why Other Choices are Incorrect:
- Choice A: While important aspects of preoperative teaching, it does not specifically address the need to elevate the affected arm post-mastectomy.
- Choice B: Pain management is crucial, but it does not directly relate to the need for arm elevation post-mastectomy.
- Choice D: Turning every 4 hours and coughing exercises are important for preventing complications but do not address the specific need for arm elevation post-mastectomy.
A nurse is performing a gynecological health history interview on a 17-year-old Caucasian adolescent. The girl appears anxious and states, 'I found a lump in my left breast, and I am worried that it may be cancer.' What factors should the nurse be aware of prior to responding to this patient? Select all that apply.
- A. Breast fibroadenomas are the most common breast tumor in women after puberty and between the ages of 15 and 30.
- B. African American women tend to develop fibroadenomas more often and at an earlier age than Caucasian women.
- C. Young women are at increased risk for breast cancer.
- D. The cause of fibroadenoma is a cancerous condition.
Correct Answer: A
Rationale: The correct answer is A because breast fibroadenomas are indeed the most common benign breast tumor in women after puberty, typically occurring between the ages of 15 and 30. The nurse should be aware of this fact when assessing the patient's concern about the lump. Fibroadenomas are non-cancerous and do not increase the risk of breast cancer.
Choice B is incorrect because fibroadenomas are more common in Caucasian women, not African American women. Choice C is incorrect because young women like the patient are generally at low risk for breast cancer. Choice D is also incorrect because fibroadenomas are not caused by cancerous conditions.
The nurse has completed instructions on ways to improve the client’s symptoms related to her rectocele. Which statement by the client indicates a need for further education?
- A. Weight loss will decrease pressure on the pelvic floor.
- B. Increasing fiber and water in my diet will help prevent constipation.
- C. Heavy lifting will not affect my rectocele.
- D. Kegel exercises will help with pelvic floor strength.
Correct Answer: C
Rationale: The correct answer is C because heavy lifting can worsen rectocele symptoms by putting strain on the pelvic floor muscles. A is correct because weight loss reduces pressure. B is correct because fiber and water prevent constipation. D is correct because Kegel exercises strengthen the pelvic floor.