Nokea
The nurse is teaching a class about breast self-examinations. A client asks if the she should have an annual mammogram. According to the American Cancer Society, how should the nurse respond?
- A. All women over age 30 should have an annual mammogram.
- B. All women over age 40 should have an annual mammogram.
- C. Any woman over age 20 whose mother had breast cancer should have an annual mammogram.
- D. Any woman who feels she is at risk for breast cancer should have an annual mammogram.
Correct Answer: B
Rationale: According to the American Cancer Society, they recommend that all women aged 40 to 44 should have the choice to start annual mammograms if they wish to do so. For women aged 45 to 54, it is recommended to have an annual mammogram. For women aged 55 and older, they can switch to mammograms every two years or continue with annual screenings. Mammograms are an important screening tool for detecting breast cancer early, especially in women over the age of 40 when the risk of developing breast cancer increases.
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A client with serum glucose level of 618mg/dl is admitted to the facility. He's awake and oriented, has hot dry skin, and has the following vital signs: temperature of 100.6F (38.1C), heart rate of 116 beats/min, and blood pressure of 108/70mHg. Based on these assessment findings, which nursing diagnosis take highest priority?
- A. Deficient volume related to osmotic diuresis
- B. Decreased cardiac output related to elevated heart rate
- C. Imbalanced nutrition: Less than body requirements related to insulin deficiency
- D. Ineffective thermoregulation related to dehydration
Correct Answer: A
Rationale: The client's serum glucose level of 618mg/dl is indicative of severe hyperglycemia, likely due to uncontrolled diabetes mellitus. The client's presentation with hot dry skin, elevated heart rate, and low blood pressure suggests dehydration as a result of osmotic diuresis, which occurs in an attempt to excrete excess glucose. With an elevated heart rate and low blood pressure, it is essential to address the deficient volume to prevent further complications such as hypovolemic shock. Rehydration and fluid replacement are crucial interventions to help restore the client's fluid balance and prevent hemodynamic instability. Addressing the deficient volume related to osmotic diuresis should take the highest priority in this case.
Children with secondary nocturnal enuresis may have
- A. UTI
- B. diabetes mellitus
- C. diabetes insipidus
- D. psychosocial stressor
Correct Answer: D
Rationale: Psychosocial stressors can trigger secondary nocturnal enuresis after a period of dryness.
Which statement, from a participant attending the class on AIDS prevention, indicates an understanding on how to reduce transmission of HIV?
- A. Mother's who are HIV positive should still be encouraged to breastfeed their babies because beast milk is superior to cow's milk
- B. I think a needle exchange program, where clean needles are exchanged for dirty needles, should be offered in every city
- C. Females taking birth control pills are protected from getting HIV
- D. It's okay to use natural skin condoms since they offer the same protection as the latex condoms
Correct Answer: B
Rationale: The correct answer is B because implementing a needle exchange program is an effective way to reduce transmission of HIV among intravenous drug users. By providing clean needles in exchange for dirty needles, the risk of sharing contaminated needles and spreading the virus is significantly reduced. This approach also helps prevent the transmission of other bloodborne diseases, such as Hepatitis C. The other statements do not demonstrate an understanding of how to reduce HIV transmission - for example, encouraging breastfeeding for HIV-positive mothers can transmit the virus to the baby, birth control pills do not protect against HIV, and natural skin condoms do not offer the same level of protection as latex condoms.
Nursing interventions for the child after a cardiac catheterization should include which actions? (Select all that apply.)
- A. Allow ambulation as tolerated.
- B. Monitor vital signs every 2 hours.
- C. Assess the affected extremity for temperature and color.
- D. Check pulses above the catheterization site for equality and symmetry.
Correct Answer: A
Rationale: Allowing ambulation as tolerated helps promote circulation and prevent complications such as blood clots.
A school nurse is conducting vision and hearing testing on fifth-grade children. Which level of prevention is the nurse demonstrating?
- A. Primary
- B. Secondary
- C. Tertiary
- D. Health promotion
Correct Answer: B
Rationale: The school nurse conducting vision and hearing testing on fifth-grade children is demonstrating the secondary level of prevention. Secondary prevention involves identifying and treating health conditions early to prevent their progression. In this scenario, the nurse's aim is to detect any existing vision or hearing problems in the children at an early stage so that appropriate interventions can be initiated to prevent further impairment or complications. This aligns with the goals of secondary prevention, which focuses on early detection, prompt intervention, and minimizing the impact of a health condition.