Nokea
The nurse is admitting a client diagnosed with trichomoniasis. Which assessment data support this diagnosis?
- A. Odorless, white, curdlike vaginal discharge.
- B. Strawberry spots on the vaginal surface and itching.
- C. Scant white vaginal discharge and dyspareunia.
- D. Purulent discharge from the endocervix and pelvic pain.
Correct Answer: B
Rationale: Trichomoniasis causes strawberry spots (petechiae) on the vagina and itching due to inflammation. Curdlike discharge is candidiasis, scant discharge/dyspareunia is nonspecific, and purulent discharge suggests PID.
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The client has been diagnosed with cancer of the breast. Which referral is most important for the nurse to make?
- A. The hospital social worker.
- B. CanSurmount.
- C. Reach to Recovery.
- D. I CanCope.
Correct Answer: C
Rationale: Reach to Recovery provides peer support from breast cancer survivors, addressing emotional and practical needs post-diagnosis. Social workers, CanSurmount, and I CanCope are valuable but less specific to breast cancer support.
The male client complains of mucus-like drainage from the rectum accompanied by rectal pain and diarrhea. Which interview question should the nurse ask the client?
- A. Do you have difficulty trying to urinate?'
- B. Have you had rectal sexual intercourse?'
- C. Do you eat a high-fiber diet and drink lots of fluids?'
- D. Does the diarrhea alternate with constipation?'
Correct Answer: B
Rationale: Rectal intercourse is a risk for proctitis or STDs causing mucus, pain, and diarrhea. Urination, diet, and diarrhea patterns are less specific.
The nurse is teaching a class on breast health to a group of ladies at a senior citizen's center. Which risk factor is the most important to emphasize to this group?
- A. The clients should find out about their family history of breast cancer.
- B. Men at this age can get breast cancer also and should be screened.
- C. Monthly breast self-examination is the key to early detection.
- D. The older a woman gets, the greater the chance of developing breast cancer.
Correct Answer: D
Rationale: Age is the most significant risk factor for breast cancer, with risk increasing as women age, especially in seniors. Family history is important but less universal, male breast cancer is rare, and BSE is secondary to awareness and screening.
Which nursing order is most appropriate to add to the client's initial postoperative care plan?
- A. Connect the cystostomy tube to a leg bag for drainage.
- B. Secure the cystostomy tube to the client's thigh.
- C. Ensure that the cystostomy tube is unclamped at all times.
- D. Clamp the indwelling catheter when the cystostomy tube is irrigated.
Correct Answer: C
Rationale: Keeping the cystostomy tube unclamped ensures continuous drainage, preventing complications like infection or pressure buildup.
Which vaccination should the nurse recommend to the postpubertal male to prevent orchitis?
- A. Yearly flu injections.
- B. Herpes varicella inoculations.
- C. Mumps vaccination.
- D. Rubella injections.
Correct Answer: C
Rationale: Mumps vaccination prevents mumps-related orchitis, a common cause in postpubertal males. Flu, varicella, and rubella are unrelated to orchitis.