Nokea
The nurse is teaching a client how to perform a testicular self-examination. What information should be provided to the client?
- A. Any painful lump should be reported.
- B. Tenderness of the scrotal sac contents should be reported.
- C. Most men have one testicle that is significantly larger than the other.
- D. It is best to do the examination upon arising on the designated day.
Correct Answer: A
Rationale: Any lump, painful or not, warrants reporting. Normal tenderness and size differences are not significant unless extreme, and timing is flexible.
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The nurse is watching the cardiac monitor, and a client's rhythm suddenly changes. There are no P waves; instead, there are fibrillatory waves before each QRS complex. How should the nurse correctly interpret the client's heart rhythm?
- A. Atrial fibrillation
- B. Sinus tachycardia
- C. Ventricular fibrillation
- D. Ventricular tachycardia
Correct Answer: A
Rationale: Fibrillatory waves with QRS complexes indicate atrial fibrillation.
A patients health assessment has resulted in a diagnosis of alopecia areata. What nursing diagnosis should the nurse most likely associate with this health problem?
- A. Chronic Pain
- B. Impaired Skin Integrity
- C. Impaired Tissue Integrity
- D. Disturbed Body Image
Correct Answer: D
Rationale: Alopecia areata causes hair loss in smaller defined areas, commonly leading to a disturbed body image.
The outer layer of the epidermis provides the most effective barrier to penetration of the skin by environmental factors. Which of the following is an example of penetration by an environmental factor?
- A. An insect bite
- B. Dehydration
- C. Sunburn
- D. Excessive perspiration
Correct Answer: A
Rationale: The stratum corneum, the outer layer of the epidermis, provides the most effective barrier to both epidermal water loss and penetration of environmental factors, such as chemicals, microbes, insect bites, and other trauma.
When explaining a tonometer test results of $28 "mathrm{~mm} "mathrm{Hg}$ to a client, the nurse would use which explanation to be most accurate?
- A. The tonometer measures the pressure in the posterior chamber of your eye, which is too low and requires medication to increase the pressure to prevent blindness from retinal damage.
- B. The tonometer measures the pressure in the inner ear, to evaluate the semicircular canals functions related to nerve damage, and 28 mmHg is 'within the normal range.'
- C. The tonometer measures the pressure in the middle ear that builds up with Mastoiditis, and $28 "mathrm{~mm} "mathrm{Hg}$ is very high, and needs to be treated with surgical insertion of tubes to drain the fluid behind the tympanic membrane.
- D. The tonometer measures the pressure in the anterior chamber of the eye that builds up from overproduction or decreased drainage of the aqueous humor, and could lead to possible retinal changes due to above-normal pressures, like yours, if not treated.
Correct Answer: D
Rationale: The tonometer measures intraocular pressure in the anterior chamber. A reading of 28 mm Hg is above normal (12-20 mm Hg), indicating potential glaucoma that could lead to retinal damage if untreated.
The nurse is assisting the patient to select foods from the menu that will promote wound healing. Which statement indicates the nurse's knowledge of nutritional goals?
- A. "Avoid foods that have saturated fats. Fats interfere with the ability of the burn wound to heal.?"
- B. "Choose foods that are high in protein
- C. such as meat
- D. eggs
Correct Answer: B
Rationale: Nutritional therapy must be instituted immediately after burn injury to meet the high metabolic demands of the body. Oral diets should be high in calories and high in protein to meet the demands of the body.