Nokea
The nurse is formulating a care plan for a client post-abdominal hysterectomy. Which nursing diagnosis is appropriate for the client who has developed a complication?
- A. Potential for urinary retention.
- B. Potential for nerve damage.
- C. Potential for intestinal obstruction.
- D. Potential for fluid imbalance.
Correct Answer: C
Rationale: Intestinal obstruction is a common complication post-abdominal hysterectomy due to adhesions or ileus. Urinary retention and fluid imbalance are risks but less specific, and nerve damage is rare.
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Which breast palpation technique is most correct?
- A. Examine the breast while using the heel of the hand.
- B. Examine the breast while using the index finger only.
- C. Examine the breast while using the index finger and thumb.
- D. Examine the breast while using the pads of the fingertips.
Correct Answer: D
Rationale: Using the pads of the fingertips allows for better sensitivity to detect lumps or changes in breast tissue during palpation, making it the most effective technique for BSE.
The client is diagnosed with benign uterine fibroid tumors. Which question should the nurse ask to determine if the client is experiencing a complication?
- A. How many periods have you missed?'
- B. Do you get short of breath easily?'
- C. How many times have you been pregnant?'
- D. Where is the location of the pain you are having?'
Correct Answer: D
Rationale: Pain location helps identify complications like fibroid degeneration or pressure on organs. Missed periods are common, shortness of breath is unrelated, and pregnancy history is less relevant.
The 30-year-old male client diagnosed with germinal cell carcinoma of the testes asks the nurse, 'What chance do I have? Should I end it all now?' Which response by the nurse indicates an understanding of the disease process?
- A. God does not want you to give up hope and end it all now.'
- B. There is a good chance for survival with standard treatment options.'
- C. There may be little hope, but ending it all is not the answer.'
- D. You have a 50/50 chance of living for at least 5 years.'
Correct Answer: B
Rationale: Germinal cell carcinoma has a high cure rate with treatment (e.g., orchiectomy, chemotherapy), offering good survival chances. Religious references, pessimism, or vague statistics are less appropriate.
Which staff nurse is best suited to care for a client with a radioactive implant?
- A. A male nurse with oncology nursing experience
- B. A female nurse who has had a hysterectomy
- C. A male nurse whose mother died of cancer
Correct Answer: A
Rationale: Oncology experience equips the nurse to safely manage a client with a radioactive implant, regardless of gender or personal history.
The female client presents to the gynecologist’s office for the fifth time with an ovarian cyst and is scheduled for an exploratory laparoscopy. The client asks the nurse, 'Why do I need to have another surgery? The other cysts have all been benign.' Which statement is the nurse’s best response?
- A. Because eventually the cysts will become cancerous.'
- B. All abnormal findings in the ovary should be checked out.'
- C. The surgery will not be painful and you will have peace of mind.'
- D. Are you afraid of having surgery? Would you like to talk about it?'
Correct Answer: B
Rationale: Persistent ovarian cysts require evaluation to rule out malignancy or complications, despite prior benign findings. Suggesting inevitable cancer is inaccurate, minimizing pain is dismissive, and addressing fear is secondary.