Nokea
The nurse is conducting a prostate screening clinic. Which sign of prostatism should the nurse question each client about?
- A. Absence of postvoid dribbling
- B. Ability to stop voiding quickly
- C. Excessive force in urinary stream
- D. Hesitancy when initiating urinary stream
Correct Answer: D
Rationale: Signs of prostatism that may be reported to the nurse are reduced force and size of urinary stream, intermittent stream, hesitancy in beginning the flow of urine, inability to stop urinating quickly, a sensation of incomplete bladder emptying after voiding, and an increase in episodes of nocturia. These symptoms are the result of pressure of the enlarging prostate on the client's urethra.
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During the admission interview, an adult client reveals that, as a child, she was sexually abused by her uncle and a male cousin. She reports that she cuts the skin of her arms, legs, and abdomen. In addition to having the client sign a no-harm contract, which nursing intervention is most important?
- A. Assist the client with finding safe ways to express her anger.
- B. Talk with the client about confronting her uncle and cousin directly.
- C. Defer talking about the abuse to prevent further self-mutilation.
- D. Discuss the possibility of the client suing her relatives for their abuse.
Correct Answer: A
Rationale: Helping the client find safe ways to express anger addresses the self-harm behavior therapeutically, promoting coping skills and safety.
You are working in a community pediatric health clinic. Which developmental task should you apply into your practice?
- A. You should apply the principles of initiative when caring for preschool children.
- B. You should apply the principles of sensorimotor thought when caring for preschool children.
- C. You should apply the principles of intimacy when caring for the adolescent.
- D. You should apply the principles of concrete operations when caring for the adolescent.
Correct Answer: A
Rationale: According to Erikson's developmental stages, preschool children (ages 3-5) are in the stage of Initiative vs. Guilt, where they develop a sense of purpose through exploration and play. This is the appropriate developmental task to apply in a pediatric clinic for this age group.
A client receiving a blood transfusion begins to have chills and headache within the first 15 minutes of the transfusion. The nurse should first:
- A. Administer acetaminophen.
- B. Take the client's blood pressure.
- C. Discontinue the transfusion.
- D. Check the infusion rate of the blood.
Correct Answer: C
Rationale: Chills and headache suggest a transfusion reaction, requiring immediate discontinuation of the transfusion to prevent further complications.
A client with a history of breast cancer is prescribed anastrozole (Arimidex). The nurse should monitor the client for which of the following adverse effects?
- A. Bone loss.
- B. Hyperglycemia.
- C. Hypertension.
- D. Weight gain.
Correct Answer: A
Rationale: Anastrozole, an aromatase inhibitor, can cause bone loss, increasing osteoporosis risk.
The nurse is reviewing the client's arterial blood gas results. Which finding would indicate that the client is experiencing respiratory acidosis?
- A. pH 7.5, PcO2 of 30
- B. pH 7.3, PcO2 of 50
- C. pH 7.3, HCO3 of 19
- D. pH 7.5, HCO3 of 30
Correct Answer: B
Rationale: In respiratory acidosis, the pH is decreased and an opposite effect is seen in the PCO2 (pH decreased, PCO2 elevated). Option 1 indicates respiratory alkalosis; option 3 indicates possible metabolic acidosis; option 4 indicates possible metabolic alkalosis.