Nokea
Nurse in clinic caring for 21-year-old client who reports sore throat. Client tells nurse he hasn't seen a doctor since high school. Which health screening should nurse expect provider to perform for this client?
- A. Testicular exam
- B. Blood glucose
- C. Fecal occult blood
- D. Prostate-specific antigen
Correct Answer: A
Rationale: The correct answer is A: Testicular exam. The provider should perform this screening for a 21-year-old male as part of routine health maintenance. Testicular cancer is most common in young males, and early detection through a testicular exam is crucial for successful treatment. Blood glucose (B) screening is typically done for diabetes risk assessment, which is less likely in a young, asymptomatic individual. Fecal occult blood (C) screening is for colorectal cancer, typically recommended for individuals over 50. Prostate-specific antigen (D) screening is for prostate cancer, which is rare in young males and not recommended without specific risk factors.
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Nurse evaluating how well client learned the info presented in teaching about heart-healthy diet. Client states she understands what to do now. Which actions by nurse should assist evaluation of client's learning?
- A. Encourage client to ask questions
- B. Ask client to explain how to select or prepare meals
- C. Encourage client to fill out eval form
- D. Ask client if she has resources for further instruction on topic
Correct Answer: B
Rationale: The correct answer is B: Ask client to explain how to select or prepare meals. This action allows the nurse to assess the client's understanding of the heart-healthy diet by evaluating their ability to articulate the key concepts and apply them practically. By explaining the process of selecting or preparing meals, the client demonstrates comprehension and application of the information provided during the teaching session. Encouraging questions (choice A) is important but may not directly assess the client's ability to implement the information. Encouraging the client to fill out an evaluation form (choice C) focuses more on feedback rather than assessing learning. Asking about additional resources (choice D) is relevant but doesn't directly assess the client's understanding of the heart-healthy diet.
Nurse reviewing CDC's immunization recommendations with parents of adolescent. Which should nurse include in this discussion? (Select all that apply.)
- A. Rotavirus
- B. Varicella
- C. Herpes zoster
- D. HPV
- E. Seasonal influenza
Correct Answer: B,D,E
Rationale: The correct answers are B, D, and E. Varicella (B) vaccine is recommended for adolescents who haven't been vaccinated before. HPV (D) vaccine is crucial for preventing certain types of cancers. Seasonal influenza (E) vaccine helps protect against the flu, which can be severe. Rotavirus (A) vaccine is typically given to infants, not adolescents. Herpes zoster (C) vaccine is for adults over 50. No information is given for choices F and G.
Security officer reviewing actions to take in event of bomb threat by phone. Which statement indicates proper understanding of procedure?
- A. I will get the caller off the phone ASAP to alert the staff
- B. I will use overhead paging to alert entire facility
- C. I will not ask any questions & just let the caller talk
- D. I will listen for background noises
Correct Answer: D
Rationale: The correct answer is D because listening for background noises can provide crucial information to identify the location or nature of the threat. By actively listening, the security officer can gather valuable details without alerting the caller. Choice A is incorrect because abruptly ending the call may prevent gathering important information. Choice B is incorrect as overhead paging may cause panic. Choice C is incorrect as asking questions can elicit useful details.
Charge nurse is designating room assignments for clients. Based on her knowledge of fall prevention, which client should be assigned to room closest to the nursing station?
- A. 43-year-old client post-op following laparoscopic cholecystectomy
- B. 61-year-old client being admitted for telemetry to rule out MI
- C. 50-year-old client post-op following open reduction internal fixation of ankle
- D. 79-year-old client post-op following below-the-knee amputation
Correct Answer: D
Rationale: The correct answer is D. The 79-year-old client post-op following below-the-knee amputation should be assigned to the room closest to the nursing station for fall prevention. This is because this client may have mobility challenges and an increased risk of falls due to the recent surgery and potential use of assistive devices. Placing the client closer to the nursing station allows for closer monitoring and quicker assistance in case of any fall-related incidents.
Choice A is incorrect because a 43-year-old client post-op following laparoscopic cholecystectomy is not necessarily at an increased risk for falls related to mobility issues.
Choice B is incorrect as a 61-year-old client being admitted for telemetry to rule out MI is not specifically at a higher risk for falls compared to the client post-amputation.
Choice C is incorrect as a 50-year-old client post-op following open reduction internal fixation of the ankle may have mobility limitations, but the risk of falls is typically lower compared to a client post
Nurse manager is reviewing care of client with seizures with nurses on unit. Which statement by a nurse requires more instruction?
- A. I will place the client on his side
- B. I will go to the nurses' station for assistance
- C. I will administer meds as prescribed
- D. I will be prepared to insert an airway
Correct Answer: B
Rationale: Correct Answer: B - "I will go to the nurses' station for assistance" requires more instruction.
Rationale: Going to the nurses' station may waste crucial time during a seizure. The nurse should stay with the client, ensure a safe environment (A), administer prescribed meds (C), and be prepared to insert an airway (D) if needed. Going to the nurses' station could delay necessary interventions. Placing the client on their side helps prevent aspiration, administering meds is essential for seizure management, and being prepared to insert an airway is crucial in case of respiratory compromise.