Nokea
The nurse is preparing a preoperative teaching plan for a client who is undergoing a bilateral breast reduction. Which aspect of the plan is the priority?
- A. Reduction of risk potential.
- B. Physiologic adaptation.
- C. Psychosocial integrity.
- D. Health promotion and maintenance.
Correct Answer: C
Rationale: Psychosocial integrity is the priority for breast reduction surgery, as it addresses body image, self-esteem, and emotional adjustment, which are significant concerns for clients undergoing this procedure.
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The nurse should teach the client with diverticulitis to integrate which of the following into a daily routine at home?
- A. Using enemas to relieve constipation.
- B. Decreasing fluid intake to increase the formed consistency of the stool.
- C. Eating a high-fiber diet when symptomatic with diverticulitis.
- D. Refraining from straining and lifting activities.
Correct Answer: D
Rationale: Refraining from straining and lifting activities prevents increased intra-abdominal pressure, reducing the risk of diverticulitis complications. Enemas, decreased fluid, or high-fiber diets during acute symptoms can worsen the condition. CN: Physiological adaptation; CL: Synthesize
A client with a spinal cord injury who has been active in sports and outdoor activities talks almost obsessively about his past activities. In tears, one day he asks the nurse, 'Why can't I stop talking about these things? I know those days are gone forever.' Which of the following responses by the nurse conveys the best understanding of the client's behavior?
- A. Be patient. It takes time to adjust to such a massive loss.'
- B. I will be sure to tell the team that reviewing the past is a form of denial. We have to help you focus on today.'
- C. Reviewing your losses is a way to help you work through your grief and loss.'
- D. It's a simple escape mechanism to go back and live again in happier times.'
Correct Answer: C
Rationale: Reflecting on past activities is part of grieving, helping the client process the loss of function.
After a bilateral adrenalectomy for Cushing's disease, the client will receive periodic testosterone injections. The expected outcome of these injections is:
- A. Balanced reproductive cycle.
- B. Maintained fluid and electrolyte balance.
- C. Stimulated protein metabolism.
- D. Stabilized mood swings.
Correct Answer: C
Rationale: Testosterone injections post-adrenalectomy stimulate protein metabolism, supporting tissue repair and muscle maintenance.
A female client diagnosed with lung cancer is to have a left lower lobectomy. Which of the following increase the client's risk of developing postoperative pulmonary complications?
- A. Height is 5 feet, 7 inches and weight is 110 lb.
- B. The client tends to keep her real feelings to herself.
- C. 8.88 stimulates and can climb one flight of stairs without dyspnea.
- D. The client is 58 years of age.
Correct Answer: A
Rationale: Low body weight (5'7€, 110 lb) indicates malnutrition, increasing the risk of postoperative pulmonary complications due to weakened respiratory muscles. Emotional suppression, good exercise tolerance, and age 58 are less directly related.
Guaifenesin (Robitussin) 300 mg four times a day has been ordered as an expectorant. The dosage strength of the liquid is 200 mg/5 mL. How many milliliters should the nurse administer for each dose?
Correct Answer: 7.5 mL
Rationale: To calculate the dose: 300 mg ÷ 200 mg/5 mL = 1.5 × 5 mL = 7.5 mL per dose.