Nokea
The clinic nurse provides instructions to a client who will begin taking oral contraceptives. Which statement by the client indicates the need for further teaching?
- A. I will take one pill daily at the same time every day.
- B. If I miss a pill, I must take it as soon as I remember.
- C. I will not need to use an additional birth control method after I start these pills.
- D. If I miss two pills, I will take them both as soon as I remember, and then two pills the next day.
Correct Answer: C
Rationale: The client must use a second birth control method during the first pill cycle of oral contraceptives to ensure protection against pregnancy. Taking the pill at the same time daily, taking a missed pill as soon as remembered, and taking two missed pills as soon as remembered with two the next day are correct actions.
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The home care nurse suspects that a client's spouse is experiencing caregiver strain. Which action should the nurse take to assess for this condition?
- A. Referring the family to a social services agency
- B. Gathering data from the caregiver and the client
- C. Waiting for the caregiver to talk about the stress
- D. Obtaining feedback from the client about the caregiver
Correct Answer: B
Rationale: Caregiver strain can occur when a client is significantly dependent on the caregiver for personal and health care needs. The nurse gathers data from the client and the caregiver to determine the caregiver's stressors and coping abilities and withholds making any referrals until the assessment is complete and the plan of care is in place. Because the nurse suspects caregiver strain, the nurse fulfills the duty to the client and family by approaching the family with the concern, gathering assessment data, and planning care. The nurse does not expect the client to assess the coping abilities of the caregiver because assessment is part of the nursing process and should not be delegated.
The community health nurse provides an educational session regarding the risk factors for cervical cancer to women in the local community. The nurse determines that further teaching is needed if a woman attending the session identifies which as a risk factor for this type of cancer?
- A. Smoking tobacco
- B. Single sex partner
- C. Early age of first intercourse
- D. Human papillomavirus (HPV) infection
Correct Answer: B
Rationale: Having a single sex partner is not a risk factor for cervical cancer. Some risk factors for cervical cancer include having multiple sexual partners or a partner who had multiple sexual partners, smoking tobacco, early age of first intercourse, and HPV infection.
The nurse is caring for a client diagnosed with syphilis. The client presents with a widespread, symmetric maculopapular rash on the palms and soles. The nurse understands that the client is in which stage of the infection?
- A. primary syphilis
- B. secondary syphilis
- C. early latent syphilis
- D. latent phase syphilis
Correct Answer: B
Rationale: A maculopapular rash on palms and soles is characteristic of secondary syphilis, following the primary chancre.
The nurse is performing a socioeconomic assessment of an Asian client. Which questions are appropriate for the nurse to ask?
- A. What do you do for a living?
- B. How much money do you make yearly?
- C. Do you have a primary health care provider?
- D. How many years of school did you complete?
- E. How different is your life here from in your homeland?
- F. What type of work did you do back in your homeland?
Correct Answer: A,C,D,E,F
Rationale: Aspects to include in a cultural assessment include biocultural history and socioeconomic status (distinct health risks can be attributed to the ecological and socioeconomic context of the culture) and the client's country of origin. Other aspects to assess include religious and spiritual beliefs, communication patterns, time orientation, caring beliefs and practices, and previous experiences with professional health care. Some specific questions to ask when performing a socioeconomic assessment are noted in the correct options. Asking the client about his or her yearly income is inappropriate, unnecessary, and unrelated to health care resources.
The nurse provides information to a client about performing a breast self-examination (BSE). The nurse determines that the client needs additional teaching if the client makes which statements? Select all that apply.
- A. The BSE must be done monthly.
- B. Lumps in my armpit area are normal.
- C. I can palpate my breasts with soapy water while showering.
- D. I should perform the examination on the day that I start my period.
- E. When I squeeze my nipples, I should expect to note some discharge.
- F. I should stand before a mirror and inspect each breast for anything unusual.
Correct Answer: B,D,E
Rationale: Any lumps in the armpit or nipple discharge are abnormal and require reporting to a healthcare provider. The BSE should be performed 2 to 3 days after menstruation ends, not on the first day, when breasts are tender. Monthly BSE, palpation with soapy water in the shower, and mirror inspection are correct techniques.