Nokea
The nurse is reinforcing teaching with the parents of a 6-year-old client who is experiencing fecal incontinence related to functional constipation. Which of the following information should the nurse reinforce? Select all that apply.
- A. Instruct your child to sit on the toilet for 30 minutes after each meal.
- B. Use a reward system, such as a sticker chart, to encourage your child.
- C. Provide your child with a foot stool to rest the feet on while sitting on the toilet.
- D. Encourage your child to increase the intake of fluids throughout the day to soften the stool.
- E. Keep a record of your child's bowel movements, laxative use, and episodes of incontinence
Correct Answer: B,C,D,E
Rationale: Reward systems, foot stools, increased fluids, and tracking bowel movements aid in managing constipation. Sitting for 30 minutes is excessive and impractical.
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To prevent keratitis in an unconscious client, the nurse should apply moisturizing ointment to the
- A. Finger and toenail quicks
- B. Eyes
- C. Perianal area
- D. External ear canals
Correct Answer: B
Rationale: Eyes. Keratitis is a corneal ulcer or abrasion. Keratitis is caused by exposure and requires application of moisturizing ointment to the exposed cornea and a plastic bubble shield or eye patch.
A client who is diagnosed with breast cancer asks the nurse, 'Am I going to die?' Which statement by the nurse promotes a therapeutic relationship?
- A. Cancer is no longer a death sentence; you may live for many years.
- B. I will ask the chaplain to come and talk to you sometime today.
- C. Many people with cancer experience fear of dying; tell me about your concerns.
- D. Tell me about your life. What are your hopes and goals for the future?
Correct Answer: C
Rationale: This response validates the client's fear and invites further discussion, fostering trust and a therapeutic relationship. A offers reassurance but may dismiss the client's emotions. B deflects to another provider without addressing the concern. D shifts focus away from the client's immediate fear, missing the opportunity to explore their feelings.
A nurse is assisting with preventive health screenings at a community health event. Which of the following client statements should the nurse recognize as a warning sign of cancer? Select all that apply.
- A. For the past few years, I get a productive cough in the winter that goes away in the spring
- B. I occasionally have heartburn an hour after I eat fried foods and sausage.
- C. Last month when I was doing my breast self-examination, I noticed a marble-sized lump.
- D. My mole is itchy, and the edges have become uneven with a blackish to bluish color.
- E. Recently I have noticed that my bowel movements appear black.
Correct Answer: C,D,E
Rationale: A breast lump, an asymmetrical/irregular mole, and black stools are potential cancer signs (breast cancer, melanoma, gastrointestinal cancer). Seasonal cough and occasional heartburn are less concerning.
The nurse is assisting with community health screening. Which of the following clients is the priority to refer for further evaluation?
- A. client with a random blood glucose of 139 mg/dL (7.1 mmol/L)
- B. client with shiny, hairless legs that are cool to the touch
- C. client who is an athlete with a heart rate of 50/min
- D. client with a blood pressure of 129/79 mm Hg
Correct Answer: B
Rationale: Shiny, hairless legs that are cool to the touch suggest peripheral artery disease, a serious condition requiring urgent evaluation. A is within normal glucose range (71-200 mg/dL). C is normal for an athlete. D indicates prehypertension, which is less urgent than vascular disease.
The nurse is reinforcing education to a group of parents about ways to decrease the risk of sudden infant death syndrome. Which of the following recommendations should the nurse suggest? Select all that apply.
- A. Breastfeeding the infant
- B. Cosleeping with the infant in the parent's bed
- C. Giving the infant a pacifier at bedtime
- D. Maintaining a smoke-free environment
- E. Placing the infant to sleep in a side-lying position
Correct Answer: A,C,D
Rationale: Breastfeeding, pacifier use, and a smoke-free environment reduce SIDS risk. Cosleeping and side-lying positions increase risk.