Nokea
The nurse is caring for a client with possible cervical cancer. What clinical data would the nurse most likely find in the client's history?
- A. Post-coital vaginal bleeding
- B. Nausea and vomiting
- C. Foul-smelling vaginal discharge
- D. Hyperthermia
Correct Answer: A
Rationale: Post-coital vaginal bleeding is a hallmark symptom of cervical cancer due to tumor friability. The other symptoms are less specific or related to advanced disease.
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A 4-year-old girl has been transferred to a step-down recovery room after a tonsillectomy yesterday. The nurse should place the child in what position while she sleeps?
- A. semi-Fowler's position
- B. supine position
- C. prone position
- D. side-lying position
Correct Answer: D
Rationale: Side-lying position post-tonsillectomy promotes drainage of secretions, reducing airway obstruction risk.
A client who is postmenopausal asks the nurse how to prevent osteoporosis. Which statement should the nurse make to the client?
- A. Eat 2 ounces of cheese each day and walk a mile a day.
- B. There are no known ways to prevent osteoporosis.
- C. Do weight-bearing exercises regularly and take hormones as ordered by your physician.
- D. Take potassium supplements daily.
Correct Answer: C
Rationale: Weight-bearing exercises and hormone therapy (if prescribed) are evidence-based methods to prevent osteoporosis, unlike the other options.
The nurse enters a client's room and finds him lying on the floor. The client says to the nurse, 'I fell because I was trying to go to the bathroom and no one answered my call light.' Which of the following actions by the nurse are correct? Select all that apply.
- A. assist the client back to bed
- B. complete an incident report
- C. notify the health care provider
- D. assess the client for any injuries
- E. document in the medical record that the client fell
Correct Answer: A,B,C,D,E
Rationale: All actions are appropriate: assist the client safely, assess for injuries, notify the provider, complete an incident report, and document the fall to ensure proper care and follow-up.
A client with epilepsy is taking phenytoin. What long-term effects should the nurse advise the client can occur with prolonged administration of phenytoin? Select all that apply.
- A. Gingival hypertrophy
- B. Hirsutism
- C. Hypertrophy of facial subcutaneous tissue
- D. Dementia
- E. Anemia
Correct Answer: A,B,E
Rationale: Phenytoin's long-term effects include gingival hypertrophy (A), hirsutism (B), and anemia (E). Facial hypertrophy (C) and dementia (D) are not associated with phenytoin.
Clients with sickle cell anemia are taught to avoid activities that cause hypoxia and hypoxemia. Which of the following activities would the nurse recommend?
- A. A family vacation in the Rocky Mountains
- B. Chaperoning the local boys club on a snow-skiing trip
- C. Traveling by airplane for business trips
- D. A bus trip to the Museum of Natural History
Correct Answer: D
Rationale: A bus trip to a museum is a low-exertion activity at sea level, minimizing the risk of hypoxia compared to high-altitude or strenuous activities.