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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A client going to surgery tells the nurse that she is an active member of the Jehovah's Witness religion. The nurse is aware that the client's spiritual beliefs prohibit:
- A. The use of antibiotics and antivirals
- B. The use of medication from pork sources
- C. The eating of shellfish
- D. The use of blood or blood products
Correct Answer: D
Rationale: Jehovah's Witnesses prohibit blood transfusions and blood products due to religious beliefs. Other options are not typically restricted.
A 32-year-old man comes to the clinic for a glycosylated hemoglobin assay (HbA1c). The result is 6%. The nurse should
- A. document the findings in the chart.
- B. call the physician about orders to adjust the insulin dosage.
- C. give him 15 g of carbohydrates.
- D. ask him to list the foods he has eaten in the last 24 hours.
Correct Answer: A
Rationale: An HbA1c of 6% indicates good diabetes control (normal 4–6%). Documenting is appropriate as no action is needed. Options B, C, and D are unnecessary.
A client with lung cancer is advised to increase the protein and kilocalorie content of his diet. Which of the following choices will best meet his need for increased protein and calories?
- A. Toast, jelly, chicken broth
- B. Crackers, butter, fresh vegetables
- C. Crackers, fresh fruit, ginger ale
- D. Crackers, cheese, fruit yogurt
Correct Answer: D
Rationale: Cheese and yogurt provide high protein and calories, ideal for a client with lung cancer needing nutritional support.
A 12-year-old child is receiving intravenous theophylline (Aminophylline). The child presents with signs of tachycardia and irritability.
Which of the following nursing actions is MOST appropriate?
- A. Decrease external stimuli in the child's room.
- B. Administer an analgesic as ordered.
- C. Notify and advise the physician of the child's status.
- D. Document the assessments and continue to observe.
Correct Answer: C
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) may help the client to cope with current symptoms, but is not highest priority (2) will mask the signs of toxicity (3) correct-signs of toxicity need to be reported to the physician (4) does not take action to resolve the problem
The nurse is caring for a client with a history of Addison’s disease.
- A. Which laboratory finding is most concerning for a client with Addison’s disease?
- B. Serum sodium of 128 mEq/L.
- C. Serum cortisol of 10 µg/dL.
- D. Blood glucose of 90 mg/dL.
- E. Serum potassium of 4.0 mEq/L.
Correct Answer: A
Rationale: A serum sodium of 128 mEq/L indicates hyponatremia, a life-threatening complication in Addison’s disease due to aldosterone deficiency, risking shock. Low cortisol is expected, and normal glucose and potassium are unremarkable.