Nokea
The nurse is performing the admission assessment on a 78-year-old female client and observes bilateral pendulous breasts with a stringy appearance. Which intervention should the nurse implement?
- A. Request a mammogram.
- B. Notify the HCP of the finding.
- C. Continue with the examination.
- D. Assess for peau d’orange skin.
Correct Answer: C
Rationale: Pendulous, stringy breasts are normal age-related changes; the nurse should continue the exam. Mammogram, HCP notification, or peau d’orange assessment are unnecessary without abnormal findings.
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The client is diagnosed with vulvar cancer. Which are the most common symptoms of cancer of the vulva?
- A. Red, painful lesions.
- B. Vulvar itching.
- C. Thin, white vulvar skin.
- D. Vaginal dryness.
Correct Answer: B
Rationale: Vulvar itching is the most common symptom of vulvar cancer, often persistent. Red lesions, thin skin, and dryness are less specific or associated with other conditions.
The client diagnosed with cancer of the prostate tells the nurse, 'I caused this by being promiscuous when I was young and now I have to pay for my sins.' Which statement is the nurse’s most therapeutic response?
- A. Why would you think prostate cancer is caused by sex?'
- B. You feel guilty about some of your actions when you were young?'
- C. Well, there is nothing you can do about that behavior now.'
- D. Have you told the HCP and been checked for an AIDS infection?'
Correct Answer: B
Rationale: Reflecting the client’s guilt validates emotions and encourages discussion, a therapeutic approach. Questioning causation, dismissing behavior, or suggesting AIDS testing is less supportive.
Which nursing actions are appropriate in this situation? Select all that apply.
- A. Notify housekeeping to come and dispose of the papers.
- B. Toss the papers in the trash.
- C. Put the papers into the shredder bin.
- D. Try to determine who left the papers unattended.
- E. State the papers neatly, placing them off to the side.
- F. Notify the office manager of the breach in confidentiality.
Correct Answer: C,F
Rationale: Unattended medical records are a breach of confidentiality under HIPAA. Shredding the papers ensures secure disposal, and notifying the office manager addresses the violation. Tossing in the trash or stacking neatly does not protect confidentiality, and housekeeping or identifying the culprit are not immediate priorities.
The client diagnosed with cancer of the testes calls and tells the nurse he is having low back pain that does not go away with acetaminophen, a nonnarcotic analgesic. Which action should the nurse implement?
- A. Ask the client to come in to see the HCP for an examination.
- B. Tell the client to use a nonsteroidal anti-inflammatory drug instead.
- C. Inform the client this means the cancer has metastasized.
- D. Encourage the client to perform lower back-strengthening exercises.
Correct Answer: A
Rationale: Low back pain in testicular cancer may indicate metastasis (e.g., to retroperitoneal nodes); HCP evaluation is urgent. NSAIDs, assuming metastasis, or exercises are inappropriate without assessment.
The nurse discusses healthy sexual behaviors with the client. Which risk factor predisposes the client to acquiring a sexually transmitted infection?
- A. Experiencing early puberty
- B. Finding sex information on the Internet
- C. Having multiple sexual partners
- D. Receiving limited sex education
Correct Answer: C
Rationale: Multiple sexual partners increase exposure to STIs, significantly raising infection risk.