Nokea
The nurse is teaching testicular self-exam to a group of young men. Which information should be included in the instructions? Select all that apply.
- A. Perform the exam once a week.
- B. Palpate each testicle between the thumb and forefinger.
- C. Palpate the spermatic cord.
- D. Look in the mirror for dimpling.
- E. Testicles should be the same size.
- F. Both testicles should be at the same level.
Correct Answer: B,C
Rationale: Palpating the testicle and spermatic cord detects lumps or abnormalities during testicular self-exam. Monthly (not weekly) exams are recommended, dimpling is for breast exams, and testicles may differ slightly in size and level.
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A low-sodium, high-potassium diet is ordered for a client. Which food selection made by the client indicates understanding of the prescribed diet?
- A. Orange juice, baked chicken, and a cucumber and tomato salad
- B. Milk, roast beef, and spinach salad
- C. Iced tea, fish sandwich, and mixed vegetables
- D. Cola, fried shrimp, and coleslaw
Correct Answer: A
Rationale: Orange juice and vegetables are high in potassium and low in sodium, aligning with the prescribed diet, unlike milk, beef, or fried foods.
The nurse is teaching a client with a new diagnosis of heart failure about carvedilol (Coreg). Which of the following instructions should the nurse include?
- A. Take the medication at bedtime.
- B. Report dizziness or lightheadedness.
- C. Stop the medication if symptoms improve.
- D. Avoid checking pulse rate.
Correct Answer: B
Rationale: Dizziness or lightheadedness may indicate hypotension, a carvedilol side effect, requiring reporting. Options A, C, and D are incorrect.
The physician has ordered insertion of a nasogastric tube to provide supplemental feedings for a client recovering from a stroke. To facilitate insertion of the nasogastric tube, the nurse should:
- A. Offer the client ice chips to swallow as the tube is advanced.
- B. Tell the client to flex his neck on his chest.
- C. Tell the client to hyperextend his neck.
- D. Place the tube in warm water.
Correct Answer: B
Rationale: Flexing the neck aligns the esophagus, facilitating nasogastric tube insertion. Ice chips increase choking risk. Hyperextension misaligns the airway. Warm water is ineffective.
A 16-year-old young woman is brought by her parents to the outpatient clinic for treatment of pelvic inflammatory disease (PID). While the nurse obtains a history, the client says bitterly, 'My parents are mean and don't really care about me.' Which of the following responses by the nurse is BEST?
- A. You feel your parents don't care about you?
- B. Your parents brought you to the clinic, didn't they?
- C. I am sure that your parents have your best interests at heart.
- D. Did you have a disagreement with your parents?
Correct Answer: A
Rationale: Reflecting the client’s feelings validates her emotions, encouraging therapeutic communication. Options B, C, and D are nontherapeutic, dismissing or challenging her statement.
A young child with a history of grand mal seizures is in public school. He is on phenobarbital and hydantoin (Dilantin) to control the seizures. His teacher tells the nurse that he has not had any seizures but he does keep falling asleep in class. What should the nurse include when discussing his drowsiness with the teacher?
- A. It is common in children who take barbiturates.
- B. It usually occurs after seizures; let him sleep.
- C. It is probably not related to his seizure disorder or treatment.
- D. It is probably a warning sign that he is about to have a seizure.
Correct Answer: A
Rationale: Phenobarbital, a barbiturate, commonly causes drowsiness, explaining the child's sleepiness in class, which should be monitored but is expected.