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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Major competencies for the nurse giving end-of-life care include:
- A. demonstrating respect and compassion, and applying knowledge and skills in care of the family and the client.
- B. assessing and intervening to support total management of the family and client.
- C. setting goals, expectations, and dynamic changes to care for the client.
- D. keeping all sad news away from the family and client.
Correct Answer: A
Rationale: Demonstrating respect, compassion, and skilled care is a core competency for end-of-life nursing, addressing both client and family needs. The other options are either incomplete or inappropriate. Basic Care and Comfort
A client being discharged from the cardiac step-down unit following a myocardial infarction (MI), is given a prescription for a beta-blocking drug. A nursing student asks the charge nurse why this drug would be used by a client who is not hypertensive. What is an appropriate response by the charge nurse?
- A. Most people develop hypertension following an MI.'
- B. A beta-Blocker will prevent orthostatic hypotension.'
- C. This drug will decrease the workload on his heart.'
- D. Beta-blockers increase the strength of heart contractions.'
Correct Answer: C
Rationale: One action of beta-blockers is to decrease systemic vascular resistance by dilating arterioles. This is useful for the client with coronary artery disease, and will reduce the risk of another MI or sudden death.
While writing a report at 3:15 in the afternoon, the nurse realizes that she forgot to chart the client's physical therapy, which occurred at 10:30 A.M. Which is the appropriate action for the nurse to take?
- A. The nurse should ask the incoming nurse to record it.
- B. The nurse should date and time an entry for 3:15 P.M., and then write 'Late entry (date: 10:30 A.M.)' before making the addition.
- C. The nurse should not add the information to the chart. She should complete an incident report for the omitted charting and forward it to the risk management department.
- D. Because it is already charted by the physical therapists in their progress notes, the nurse does not need to 'double chart' the same information. The nurse does not have to do anything.
Correct Answer: B
Rationale: A late entry with the correct time (10:30 A.M.) ensures accurate documentation, maintaining the integrity of the medical record.
Which play activity is most appropriate for a 3-year-old with a hip spica cast?
- A. Barbie doll and accessories
- B. Toy telephone
- C. Coloring book and crayons
- D. Puzzle
Correct Answer: C
Rationale: A coloring book and crayons allow a 3-year-old in a hip spica cast to engage in a stationary, creative activity, so C is correct. Barbie dolls , toy telephone , and puzzles may be difficult due to the cast's restrictions.
A client arrived in the USA from a developing country 1 week ago. The client is to be admitted to the medical surgical unit with a diagnosis of AIDS. There is a history of these findings: unintended weight loss, drug abuse, night sweats, productive cough, and a 'feeling of being hot all the time.' The nurse should assign the client to share a room with a client with the diagnosis of
- A. Acute tuberculosis with a productive cough of discolored sputum for over three months
- B. Lupus and vesicles on one side of the middle trunk from the back to the abdomen
- C. Pseudomembranous colitis and C. difficile
- D. Exacerbation of polyarthritis with severe pain
Correct Answer: A
Rationale: Acute tuberculosis with a productive cough of discolored sputum for over three months. The client being admitted has the classic findings of pulmonary tuberculosis. Of the available choices, the client in option A would be the most appropriate roommate. It is acceptable to put clients with similar diagnoses in the same room when no other alternative exists. Clients are considered contagious until the cough is eliminated with medications, which initially is a combination of 4 simultaneous drugs.