Nokea
The nurse is teaching a group of college students about breast self-examination. A woman asks for the best time to perform the monthly exam. What is the best reply by the nurse?
- A. The first of every month, because it is easiest to remember'
- B. Right after the period, when your breasts are less tender'
- C. Do the exam at the same time every month'
- D. Ovulation, or mid-cycle is the best time to detect changes'
Correct Answer: B
Rationale: The best time for a breast self-exam (BSE) is a week after a menstrual cycle, when the breasts are no longer swollen and tender due to hormone elevation.
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The nursing intervention that best describes treatment to deal with the behaviors of clients with personality disorders include
- A. Pointing out inconsistencies in speech patterns to correct thought disorders
- B. Accepting client and the client's behavior unconditionally
- C. Encouraging dependency in order to develop ego controls
- D. Consistent limit-setting enforced 24 hours per day
Correct Answer: D
Rationale: Consistent limit-setting enforced 24 hours per day. This helps restructure maladaptive behaviors in personality disorders.
Which of the following nursing assessments will be MOST helpful in determining subtle changes in the client's level of consciousness?
- A. Client posturing.
- B. Glasgow coma scale.
- C. Client thinking pattern.
- D. Occurrence of hallucinations.
Correct Answer: B
Rationale: Strategy: Think about each answer choice. (1) indicates increased intracranial pressure (2) correct-Glasgow coma scale score best evaluates changes in a client's level of consciousness by evaluating eye-opening, motor, and verbal responses (3) more appropriate for the psychiatric client (4) more appropriate for the psychiatric client
Which statement made by an adolescent indicates understanding of how to reduce risk of osteoporosis later in life?
- A. I will be careful not to sprain my ankle when I play sports.'
- B. I drink a glass of milk with every meal.'
- C. As I get older, I will reduce the amount of weight-bearing exercise I do.'
- D. My favorite beverages are cola drinks.'
Correct Answer: B
Rationale: High calcium intake (milk) builds bone density, reducing osteoporosis risk. Sprains, reduced exercise, or cola drinks don't address bone health.
Which woman should be directed to come to the health care facility IMMEDIATELY?
- A. A multipara woman who is four weeks pregnant and reporting unilateral, dull abdominal pain.
- B. A primipara woman who is seven weeks pregnant and reporting an increase in whitish vaginal secretions.
- C. A primigravida woman who is five weeks gestation and is having vaginal spotting and some cramping.
- D. A multigravida woman who is six weeks pregnant and reporting frank, red vaginal bleeding with moderate cramps.
Correct Answer: A
Rationale: Strategy: Determine the least stable client. (1) correct-needs to be evaluated for an ectopic pregnancy (2) expect during first trimester of pregnancy (3) symptomatic of threatened abortion; instruct to decrease activity (4) symptoms of spontaneous abortion; instruct client to save and count pads
The nurse is caring for a client who is receiving chemotherapy and has a platelet count of 50,000/mm^3. Which of the following actions is the PRIORITY?
- A. Administer pain medication as needed.
- B. Monitor for signs of bleeding.
- C. Encourage the client to ambulate.
- D. Provide a soft diet.
Correct Answer: B
Rationale: A platelet count of 50,000/mm^3 indicates thrombocytopenia, increasing bleeding risk. Monitoring for bleeding (e.g., petechiae, hematomas) is the priority to detect complications early. Options A, C, and D are secondary: pain management, ambulation, and diet are less urgent.