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The nurse is participating in a free community health screening with a group of student nurses. Which statement by a student nurse requires further teaching by the licensed nurse?
- A. Colorectal cancer screening should begin at age 50.
- B. Men should have a prostate-specific antigen test starting at age 55.
- C. High-density lipoprotein should be greater than 50 mg/dL for women.
- D. Risk factors for hypertension include being over age 60 and leading a sedentary lifestyle.
Correct Answer: B
Rationale: Prostate-specific antigen testing typically starts at age 50, not 55, for average-risk men. Other statements are accurate.
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The nurse is giving a client with chronic obstructive pulmonary disease (COPD) information related to the positions used to breathe more easily. The nurse teaches the client to assume which position?
- A. Sit bolt upright in bed with the arms crossed over the chest.
- B. Lie on the side with the head of the bed at a 45-degree angle.
- C. Sit in a reclining chair tilted slightly back with the feet elevated.
- D. Sit on the edge of the bed with the arms leaning on an overbed table.
Correct Answer: D
Rationale: Proper positioning can decrease episodes of dyspnea in a client with COPD. Appropriate positions include sitting upright while leaning on an overbed table, sitting upright in a chair with the arms resting on the knees, and leaning against a wall while standing. Sitting bolt upright with arms folded across the chest restricts the movement of the anterior and posterior walls of the lung, and side-lying with the head of bed raised to a 45-degree position restricts the expansion of the lateral wall of the lung. Option 3 restricts posterior lung expansion.
Dipyridamole has been prescribed for the client who underwent a valve replacement, and the nurse has provided teaching to the client about the medication. Which statement indicates that the client understands the medication instructions?
- A. This medication will prevent a stroke.
- B. This medication will prevent a heart attack.
- C. This medicine will protect my artificial heart valve.
- D. This medication will help me keep my blood pressure down.
Correct Answer: C
Rationale: Dipyridamole is an antiplatelet medication. It may be administered in combination with warfarin sodium to protect the client's artificial heart valves. Dipyridamole does not prevent stroke or heart attacks. It is an antiplatelet medication rather than an antihypertensive.
The clinic nurse is providing instructions to a client in the third trimester of pregnancy regarding relief measures for heartburn. Which instruction should the nurse provide to the client?
- A. Sip on milk or hot tea.
- B. Use antacids that contain sodium.
- C. Eat fatty foods once a day in the morning only.
- D. Eat three large meals a day rather than small, frequent meals.
Correct Answer: A
Rationale: Sipping on milk or hot tea can soothe the gastrointestinal tract and relieve heartburn. Antacids containing sodium should be avoided to prevent edema. Fatty foods should be avoided entirely, and small, frequent meals are recommended to reduce heartburn in pregnancy.
The nurse is caring for a client who is a survivor of a disaster event. The client begins to display behaviors not demonstrated before. Which manifestations should indicate to the nurse that the client may be experiencing post-traumatic stress disorder (PTSD)? Select all that apply.
- A. Irritability and sleep disturbances
- B. Flashbacks or recollections of the disaster
- C. Regression to an earlier developmental stage
- D. A feeling of estrangement or detachment from others
- E. Consistent discussion and rationalizing as to why the disaster occurred
- F. Repression or the inability to remember an important aspect associated with the disaster
Correct Answer: A,B,D,F
Rationale: PTSD involves recurrent flashbacks, irritability, sleep disturbances, estrangement, and repression of trauma-related memories. Regression and rationalizing the event's cause are not typical PTSD symptoms. These manifestations indicate a sustained maladaptive response to the traumatic event, often with avoidance of trauma-related stimuli and psychological distress.
The nurse provides instructions to a new mother who is about to breastfeed her newborn infant. The nurse observes the new mother as she breastfeeds for the first time and determines the mother needs further teaching if the new mother applies which technique?
- A. Turns the newborn infant on his side, facing the mother
- B. Tilts up the nipple or squeezes the areola, pushing it into the newborn's mouth
- C. Draws the newborn the rest of the way onto the breast when the newborn opens his mouth
- D. Places a clean finger in the side of the newborn's mouth to break the suction before removing the newborn from the breast
Correct Answer: B
Rationale: The mother should avoid tilting up the nipple or squeezing the areola and pushing it into the newborn's mouth, as this can lead to improper latch or difficulties with milk flow. Turning the newborn on his side facing the mother, drawing the newborn onto the breast when the mouth opens, and breaking suction with a clean finger are appropriate breastfeeding techniques.