Nokea
The female client presents to the clinic for an examination because she has not had a menstrual cycle for several months and wonders if she could be pregnant. The client is 5'10 tall and weighs 45 kg. Which assessment data should the nurse obtain first?
- A. Ask the client to recall what she ate for the last 24 hours.
- B. Determine what type of birth control the client has been using.
- C. Reweigh the client to confirm the data.
- D. Take the client's pulse and blood pressure.
Correct Answer: D
Rationale: Low weight (BMI ~13.6) suggests anorexia, and vital signs (pulse, BP) assess for hemodynamic instability, a priority. Diet recall, birth control, and reweighing are secondary.
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The client tells the nurse about being diagnosed with a 2-cm cancerous tumor in the liver. The client wants to know about the treatment. Which statement should be the basis for the nurse’s response?
- A. The use of chemotherapy is the first-line treatment for liver cancer.
- B. Liver transplantation is not an option for clients with liver cancer.
- C. Radiofrequency ablation can be successful in treating tumors of this size.
- D. A tumor of this size can only be removed through an open surgical approach.
Correct Answer: C
Rationale: A. Chemotherapy is only used for clients who are not likely to benefit from other therapies. B. Liver transplantation is used when the tumor is large or localized. C. Radiofrequency ablation is a treatment technique that uses high-frequency alternating electrical current to heat tissue cells and destroy them. It can be successfully used to treat tumors less than 5 cm in size because these tumors tend to be slow growing and encapsulated. D. Surgical resection of the tumor is used when the tumor is large or localized.
The nurse writes the problem 'risk for impaired skin integrity' for a client with a sigmoid colostomy. Which expected outcome would be appropriate for this client?
- A. The client will have intact skin around the stoma.
- B. The client will be able to change the ostomy bag.
- C. The client will express anxiety about the body changes.
- D. The client will maintain fluid balance.
Correct Answer: A
Rationale: Intact skin around the stoma directly addresses the risk for impaired skin integrity due to colostomy leakage or irritation. Other outcomes are unrelated or secondary.
The nurse is caring for the client diagnosed with hemorrhoids. Which statement indicates further teaching is needed?
- A. I should increase fruits, bran, and fluids in my diet.
- B. I will use warm compresses and take sitz baths daily.
- C. I must take a laxative every night and have a stool daily.
- D. I can use an analgesic ointment or suppository for pain.
Correct Answer: C
Rationale: Daily laxatives are not necessary and may cause dependency; hemorrhoid management focuses on diet and symptom relief. Increased fiber/fluids, sitz baths, and analgesics are correct.
The RN overhears the LPN talking with the client who is being prepared for a total colectomy with the creation of an ileoanal reservoir for ulcerative colitis. Which statement made by the LPN should the RN clarify to decrease the client’s anxiety?
- A. “This surgery will prevent you from developing colon cancer.”
- B. “After this surgery you will no longer have ulcerative colitis.”
- C. “After surgery you may not have solid food for several days.”
- D. “You’ll have a permanent ileostomy after having this surgery.”
Correct Answer: D
Rationale: A. The client will not be at risk for colon cancer because with a total colectomy the entire colon is removed. B. Since this surgery removes the total colon, the ulcerative colitis will be cured. C. The client will be unable to eat until peristalsis returns, and then it may take several days before solid foods are tolerated. D. The client will initially have an ileostomy; after the reservoir has healed, the ileostomy will be closed. Knowing that the ileostomy will be temporary is important information for the client to decrease anxiety.
The nurse is completing the client’s hospital admission history. Which statement should prompt the nurse to further question the client about symptoms associated with GERD?
- A. “I have been experiencing headaches immediately after eating.”
- B. “Lately, I wake up at night with a burning feeling in my chest.”
- C. “I have been waking up at night sweating and wet all over.”
- D. “Immediately after eating I feel sleepy and want to go to bed.”
Correct Answer: B
Rationale: A. Headaches are a symptom not related to GERD. B. Heartburn, which is described as a burning, tight sensation in the lower sternum, is the most common symptom of GERD. It will often wake the client from sleep. C. Night sweats are a symptom not related to GERD. D. Postprandial sleepiness is a symptom not related to GERD.