Nokea
The nurse finds the client who has had an ileostomy crying. The client explains to the nurse, 'I'm upset because I know I won't be able to have children now that I have an ileostomy.' Which of the following would be the best response for the nurse?
- A. Many women with an ileostomy can still have children; let's discuss your concerns with your doctor.
- B. Having an ileostomy does prevent pregnancy, but you can explore adoption.
- C. This is a common feeling; would you like to talk more about it?
- D. I'll RAW arrange for a counselor to discuss your fertility options.
Correct Answer: A
Rationale: The nurse should reassure the client that many women with ileostomies can still have children and offer to discuss this with the doctor, addressing the misconception directly. The other options either reinforce the misconception, avoid the concern, or defer without providing immediate support. CN: Psychosocial adaptation; CL: Synthesize
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A 52-year-old client is scheduled for a total abdominal hysterectomy for cervical cancer. The nurse is preparing preoperative teaching. Which of the following should be included in the teaching plan to address potential changes in sexuality?
- A. Sexual intercourse will not be possible after surgery.
- B. Vaginal dryness may occur, and water-soluble lubricants can help.
- C. Menopausal symptoms will not occur if ovaries are preserved.
- D. Sexual desire will remain unchanged after surgery.
Correct Answer: B
Rationale: Vaginal dryness is a common side effect after hysterectomy due to changes in vaginal tissue and potential hormonal shifts, even if ovaries are preserved. Teaching about water-soluble lubricants helps the client prepare for and manage this change.
College freshman are participating in a study abroad program. When teaching them about hepatitis B, the nurse should instruct the students on:
- A. Water sanitation.
- B. Single dormitory rooms.
- C. Vaccine for hepatitis B.
- D. Safe sexual practices.
Correct Answer: D
Rationale: Hepatitis B is transmitted via blood and body fluids, so safe sexual practices (D) are critical for prevention. Water sanitation (A) is more relevant for hepatitis A. Single rooms (B) are unnecessary. The vaccine (C) is preventive but not the focus of behavioral instruction.
The nurse is assessing a client with macular degeneration. Identify the illustration that best depicts what clients with this disorder typically see
- A. degeneration-1.png
- B. degeneration-2.png
- C. degeneration-3.png
- D. degeneration-4.png
Correct Answer: C
Rationale: In macular degeneration the center vision is blackened out and only the outer visual fields are clear.
A client with ascites and peripheral edema is at risk for impaired skin integrity. To prevent skin breakdown, the nurse should:
- A. Institute range-of-motion (ROM) exercise every 4 hours.
- B. Massage the abdomen once a shift.
- C. Use an alternating air pressure mattress.
- D. Elevate the lower extremities.
Correct Answer: C
Rationale: An alternating air pressure mattress (C) prevents pressure ulcers in clients with edema. ROM exercises (A) and elevation (D) are helpful but secondary. Abdominal massage (B) is not indicated.
The client with acute leukemia and the health care team establish mutual client outcomes of improved tidal volume and activity tolerance. Which measure would be least likely to promote outcome achievement?
- A. Ambulating in the hallway.
- B. Sitting up in a chair.
- C. Lying in bed and taking deep breaths.
- D. Using a stationary bicycle in the room.
Correct Answer: C
Rationale: Improving tidal volume and activity tolerance requires active movement to enhance lung expansion and stamina. Ambulating, sitting up, and using a stationary bicycle promote these outcomes. Lying in bed, even with deep breaths, is passive and least effective.