Nokea
The client who has had a mastectomy tells the nurse, 'My husband will leave me now since I am not a whole woman anymore.' Which response by the nurse is most therapeutic?
- A. You're afraid your husband will not find you sexually appealing?'
- B. Your husband should be grateful you will be able to live and be with him.'
- C. Maybe your husband would like to attend a support group for spouses.'
- D. You don't know that is true. You need to give him a chance.'
Correct Answer: A
Rationale: Reflecting the client’s fear validates her emotions and encourages discussion, a therapeutic approach. Gratitude dismisses feelings, support groups are premature, and reassurance without exploration is less effective.
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When carrying out this intervention, which action is most appropriate?
- A. Apply ice to the site in a sealed plastic bag.
- B. Place a covered ice pack to the scrotum.
- C. Position the client on a hypothermia blanket.
- D. Seat the client on an ice-filled ring.
Correct Answer: B
Rationale: A covered ice pack reduces swelling and pain in the scrotum safely and effectively post-hydrocele aspiration.
If the lump has the following characteristics when the nurse palpates the breast tissue, which one is most suggestive that the lump may be a common?
- A. The lump can be easily moved about.
- B. The lump is about 1/2" (1 cm).
- C. The lump is irregularly shaped.
- D. The lump is near the areola.
Correct Answer: C
Rationale: Irregularly shaped lumps are more suggestive of malignancy, as benign lumps are typically smooth and mobile. Size, mobility, and location near the areola are less specific indicators.
Which instruction is most appropriate if a Papanicolaou (Pap) smear will be obtained at the time of the pelvic examination?
- A. Avoid douching for several days before your appointment.
- B. Stop using any and all forms of contraception temporarily.
- C. Drink at least 1 quart of liquid an hour before your appointment.
- D. Avoid having sexual intercourse for a week before the test.
Correct Answer: A
Rationale: Douching can wash away cervical cells, leading to inaccurate Pap smear results, so it should be avoided for several days prior to the test.
When a client with a transurethral resection of the prostate (TURP) complains of bladder discomfort and a feeling of urgency to void, which nursing action is best to take first?
- A. Check that the urinary drainage catheter is patent.
- B. Administer a prescribed analgesic as soon as possible.
- C. Change the client to semi-Fowler's position.
- D. Get the client out of bed to ambulate for a while.
Correct Answer: A
Rationale: Ensuring catheter patency addresses the most likely cause of discomfort (blockage or clots) and prevents complications like bladder distension.
The nurse is caring for a client who is eight (8) hours postoperative unilateral orchiectomy for cancer of the testes. Which intervention should the nurse implement?
- A. Provide an athletic supporter before ambulating.
- B. Encourage the client to delay use of pain medications.
- C. Place the client on a clear liquid diet for the first 48 hours.
- D. Monitor the PT/INR levels and have vitamin K ready.
Correct Answer: A
Rationale: An athletic supporter reduces scrotal swelling and discomfort during ambulation post-orchiectomy. Delaying pain medication, clear liquids, and PT/INR monitoring are inappropriate.