Nokea
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.
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A client at the family planning clinic requests a prescription for oral contraceptives from the nurse who is performing an assessment. After reviewing the client's chart, the nurse determines that oral contraceptives are contraindicated because of which documented item? (Refer to chart.)
- A. Has renal calculi
- B. Blood pressure: 108 / 72mmHg
- C. Had thrombotic stroke at age 35 years
- D. Apical heart rate: 72 beats/min
Correct Answer: C
Rationale: Oral contraceptives are contraindicated in women with a history of thrombophlebitis and thromboembolic disorders; cardiovascular or cerebrovascular diseases (including stroke [brain attack]); any estrogendependent cancer or breast cancer, or benign or malignant liver tumors; impaired liver function; hypertension; or diabetes mellitus with vascular involvement. Adverse effects of oral contraceptives include increased risk of superficial and deep vein thrombosis, pulmonary embolism, thrombotic stroke (or other types of strokes), myocardial infarction, and accelerations of preexisting breast tumors.
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 instructing a client diagnosed with type 1 diabetes mellitus about the management of hypoglycemic reactions. The nurse instructs the client that hypoglycemia most likely occurs during what time interval after insulin administration?
- A. Peak
- B. Onset
- C. Duration
- D. Anytime
Correct Answer: A
Rationale: Insulin reactions are most likely to occur during the peak time after insulin administration, when the medication is at its maximum action. Peak action depends on the type of insulin, the amount administered, the injection site, and other factors.
The nurse is evaluating a hypertensive client's understanding of dietary modifications to control the disease process. The nurse determines that the client's understanding is satisfactory if the client made which meal selections?
- A. Corned beef, fresh carrots, boiled potato
- B. Hot dog on a bun, sauerkraut, baked beans
- C. Turkey, baked potato, salad with oil and vinegar
- D. Scallops, French fries, salad with bleu cheese dressing
Correct Answer: C
Rationale: Hypertensive clients should avoid high-sodium foods like corned beef, hot dogs, sauerkraut, scallops, French fries, and bleu cheese dressing. Turkey, baked potato, and salad with oil and vinegar are low in sodium, indicating correct dietary understanding.
The nurse creates a teaching plan regarding the administration of eardrops for the parents of a 6-year-old child. The nurse tells the parents that, when administering the drops, which action is appropriate?
- A. Wear gloves.
- B. Pull the ear up and back.
- C. Hold the child in a sitting position.
- D. Position the child so that the affected ear is facing downward.
Correct Answer: B
Rationale: To administer eardrops in a child who is more than 3 years old, the ear is pulled upward and back. The ear is pulled down and back in children less than 3 years old. Gloves do not need to be worn by the parents, but hand washing before and after the procedure must be performed. The child needs to be in a side-lying position with the affected ear facing upward to facilitate the flow of medication down the ear canal with the help of gravity.