Nokea
The nurse is planning to teach a teenage client about sexuality. What should the nurse do first?
- A. Inform the teenager about the dangers of pregnancy.
- B. Establish a relationship and determine prior knowledge.
- C. Advise the teenager to maintain sexual abstinence until marriage.
- D. Provide written information about sexually transmitted infections.
Correct Answer: B
Rationale: The first step in effective communication is establishing a relationship. By exploring the client's interest and prior knowledge, rapport is established, and learning needs are assessed. The other options may or may not be later steps, depending on the data obtained.
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The nurse is teaching a client diagnosed with histoplasmosis infection about the prevention of future exposure to infectious sources. The nurse determines that the client needs further instruction if the client states that which is a potential source of this infection?
- A. Grape arbors
- B. Bird droppings
- C. Mushroom cellars
- D. Floors of chicken houses
Correct Answer: A
Rationale: Grape arbors do not harbor the causative organism for histoplasmosis. The client diagnosed with histoplasmosis is taught to avoid exposure to potential sources of the fungus, including bird droppings (especially those of starlings and blackbirds), mushroom cellars, and the floors of chicken houses and bat caves.
The nurse has completed discharge teaching with the parents of a child diagnosed with glomerulonephritis. Which statement by the parents indicates that further teaching is necessary?
- A. We'll check our child's blood pressure every day.
- B. We'll test our child's urine for albumin every week.
- C. It'll be so good to have our child back in tap-dancing classes next week.
- D. We'll be sure that our child eats a lot of vegetables and does not add extra salt to food.
Correct Answer: C
Rationale: Tap dancing classes 1 week after discharge would be unrealistic and involve a too rapid increase in activity. Glomerulonephritis results in destruction, inflammation, and sclerosis of the glomeruli of the kidneys. After discharge, parents should allow the child to return to his or her normal routine and activities, with adequate periods allowed for rest. Taking daily blood pressure, testing urine weekly for albumin, and restricting extra sodium are appropriate home care measures.
The nurse is providing education at a senior center. Which of the following measures will the nurse say is most effective in attaining normal blood pressure in a client with hypertension?
- A. eating red meat daily
- B. increasing potassium and calcium intake
- C. increasing fluid intake
- D. decreasing sodium intake
Correct Answer: D
Rationale: Decreasing sodium intake is the most effective dietary measure to manage hypertension, as sodium increases blood pressure. Red meat (A) may worsen it, potassium/calcium (B) is supportive but less impactful, and fluid intake (C) is not directly related.
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.
The nurse is caring for a pregnant client at 24 weeks. The client voids before the nurse measures the fundal height. Which finding by the nurse would be expected in assessment of this client?
- A. a fundal height of 22 to 26 cm
- B. a fundal height of 27 to 30 cm
- C. a fundal height of 29 to 33 cm
- D. a fundal height of 31 to 34 cm
Correct Answer: A
Rationale: At 24 weeks, fundal height typically measures 22-26 cm, corresponding to gestational age in centimeters.