Nokea
The nurse in the pediatric clinic performs a physical assessment of a 13-year-old boy. Which of the following findings by the nurse requires an immediate intervention?
- A. The adolescent complains of his scrotum aching after exercise. The nurse palpates a worm-like mass above the testes
- B. The nurse noted unilateral breast enlargement
- C. The child's scrotum appears swollen, and a soft mass is palpated. The nurse is unable to insert a finger above the mass
- D. The child's scrotum appears enlarged and red. The nurse palpated a thickened and swollen spermatic cord.
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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The nurse in the pediatric clinic performs a physical assessment of a 13-year-old boy. Which of the following findings by the nurse requires immediate intervention?
- A. The adolescent complains of his scrotum aching after exercise. The nurse palpates a worm-like mass above the testes.
- B. The nurse noted unilateral breast enlargement.
- C. The child's scrotum appears swollen, and a soft mass is palpated. The nurse is unable to insert a finger above the mass.
- D. The child's scrotum appears enlarged and red. The nurse palpated a thickened and swollen spermatic cord.
Correct Answer: D
Rationale: Choice D is the correct answer because a swollen and thickened spermatic cord could indicate testicular torsion, which is a surgical emergency. Testicular torsion occurs when the spermatic cord twists, cutting off the blood supply to the testicle. This condition requires immediate intervention to prevent testicular damage. Choices A, B, and C do not present findings that suggest a surgical emergency requiring immediate intervention.
The client with peripheral venous disease is scheduled to go to the whirlpool for a dressing change. What is the nurse's priority intervention?
- A. Escort the client to the physical therapy department
- B. Medicate the client 30 minutes before going to the whirlpool
- C. Obtain the sterile dressing supplies for the client
- D. Assist the client to the bathroom prior to the treatment
Correct Answer: B
Rationale: The correct answer is B. Pain management is essential before the procedure to ensure the client's comfort and cooperation during the dressing change. Escorting the client to the physical therapy department (Choice A) is not the priority at this point. Obtaining sterile dressing supplies (Choice C) is important but not the priority before addressing pain management. Assisting the client to the bathroom (Choice D) is not the priority intervention for a dressing change in the whirlpool.
Which of the following is a nonmedical member of a unit who receives additional training in providing care beyond basic first aid procedures?
- A. Area support squad leader
- B. ATLS specialist
- C. Tactical lifesaver
- D. Combat lifesaver
Correct Answer: D
Rationale: The correct answer is D, Combat lifesaver. A Combat Lifesaver is a nonmedical member of a unit who receives specialized training in advanced first aid procedures, beyond basic first aid care. This training equips them to provide crucial medical assistance in emergency situations where immediate medical personnel may not be available. Choices A, B, and C are incorrect as they do not specifically refer to nonmedical members trained in advanced first aid care beyond basic procedures.
A patient with Crohn's disease is experiencing diarrhea. Which dietary recommendation is appropriate?
- A. High-fiber diet
- B. Low-residue diet
- C. High-fat diet
- D. High-protein diet
Correct Answer: B
Rationale: A low-residue diet is appropriate for a patient with Crohn's disease experiencing diarrhea because it helps reduce bowel movements and manage symptoms. Choice A, a high-fiber diet, can exacerbate diarrhea in Crohn's disease due to increased bulk and fermentation in the gut. Choice C, a high-fat diet, may be hard to digest and can worsen symptoms. Choice D, a high-protein diet, can be taxing on the digestive system and may not provide the relief needed for diarrhea in Crohn's disease.
The unlicensed nursing assistant is applying elastic compression stockings to the client. Which action by the assistant warrants immediate intervention by the nurse?
- A. The assistant is putting the stockings on while the client is in the chair
- B. The assistant inserted two (2) fingers under the proximal end of the stocking
- C. The assistant elevated the feet while lying down to put on the stockings
- D. The assistant made sure the toes were warm after putting the stockings on
Correct Answer: A
Rationale: The correct answer is A. Compression stockings should be applied while the client is lying down to prevent pooling of blood in the legs, which can occur when the client is sitting or standing. Choice B is incorrect as inserting two fingers under the proximal end of the stocking helps ensure proper fit. Choice C is incorrect as elevating the feet while lying down is a correct technique for applying compression stockings. Choice D is incorrect as ensuring the toes are warm after putting the stockings on is a good practice for client comfort.