Nokea
The nurse employed in a woman's health care clinic would be most concerned about which client statement?
- A. I recently noticed a small, round, painless, mobile lump in my left breast while showering.
- B. Last night while breastfeeding, my nipples were cracked and my breasts were painful.
- C. My right breast is red and warm with little tiny indented areas on the surface of the skin.
- D. Sometimes during my cycle, I notice breast nodules that are movable and feel soft to the touch.
Correct Answer: C
Rationale: Red, warm breast with indented skin suggests inflammatory breast cancer, requiring urgent evaluation. A mobile lump is often benign, nipple pain is common in breastfeeding, and cyclic nodules are typically hormonal.
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A client with AIDS shows symptoms of herpes simplex stomatitis. Which drug therapy can be anticipated for the client?
- A. Lypressin (Vasopressin)
- B. Liothyroxine (Triostat)
- C. Acyclovir (Zovirax)
- D. Dexamethasone (Maxidex)
Correct Answer: C
Rationale: Acyclovir is an antiviral drug used to treat herpes simplex infections, including stomatitis in AIDS patients.
A client with diabetes phones the clinic stating, 'I have a terrible cold and I don't know what to do about taking my insulin.' Which of the following should be included in the nurse's teaching regarding the client's insulin needs?
- A. Infections decrease insulin needs, so she should withhold insulin injections until her cold symptoms improve.
- B. Infections cause a drop in blood glucose levels, so she should base her insulin needs on the results of urine glucose tests.
- C. Infections cause alterations and increase insulin needs, so she should check her blood glucose levels and urine ketones at least every 4 hours.
- D. Infections cause no change in insulin requirements, but she should avoid crowds and overfatigue.
Correct Answer: C
Rationale: Infections increase insulin resistance, raising insulin needs. Frequent glucose and ketone monitoring ensures proper management. Withholding insulin or relying on urine tests is dangerous, and infections do alter insulin requirements.
The nurse is observing the parent feed a 3-month-old diagnosed with gastroesophageal reflux. Which action by the parent indicates that further teaching is necessary?
- A. The parent does not push the infant to finish the bottle
- B. The parent engages the infant in active play after the feeding
- C. The parent interrupts the feeding to burp the infant
- D. The parent supports the infant upright during the feeding
Correct Answer: B
Rationale: Active play post-feeding can worsen reflux. Not forcing the bottle , burping , and upright positioning are appropriate.
The nurse is feeding a client who experienced a right-sided stroke and has dysphagia and hemianopsia. Which of the following actions would be appropriate for the nurse to take? Select all that apply.
- A. Encourage the client to turn the head to the left occasionally while eating
- B. Add milk to the client's mashed potatoes to make the consistency thinner.
- C. Provide a straw for the client to use while drinking a fruit smoothie.
- D. Place food on the stronger side of the client's mouth
- E. Assist the client to sit in an upright position.
Correct Answer: D,E
Rationale: Placing food on the stronger side and upright positioning reduce aspiration risk. Head turning may not help right-sided stroke, thinning food increases aspiration, and straws are unsafe.
A new nurse manager is seeking a mentor in the administrative realm. Which of these characteristics is a priority for the outcome of a positive experience with a mentor?
- A. Information is clarified as needed
- B. A teacher-coach role is taken by the mentor
- C. The mentee accepts feedback objectively
- D. The mentor is randomly assigned by administration
Correct Answer: B
Rationale: A teacher-coach role is taken by the mentor. A mentor who guides and coaches fosters a productive learning experience.