Nokea
The nurse writes a client problem of urinary retention for a client diagnosed with Stage IV cancer of the prostate. Which intervention should the nurse implement first?
- A. Catheterize the client to determine the amount of residual.
- B. Encourage the client to assume a normal position for urinating.
- C. Teach the client to use the Valsalva maneuver to empty the bladder.
- D. Determine the client’s normal voiding pattern.
Correct Answer: A
Rationale: Catheterization assesses residual urine, confirming retention and guiding treatment in advanced prostate cancer. Positioning, Valsalva, and voiding patterns are secondary.
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The client is being discharged after a left wedge resection. Which discharge instructions should the nurse include? Select all that apply.
- A. Notify the HCP of a temperature of 100°F.
- B. Carry large purses and bundles with the right hand.
- C. Do not go to church or anywhere with crowds.
- D. Try to keep the arm as still as possible until seen by the HCP.
- E. Have a mammogram of the right and left breasts yearly.
Correct Answer: A,B,E
Rationale: Notify HCP for fever (infection risk), use right hand for heavy items (protect left arm), and annual mammograms (continued screening) are appropriate. Avoiding crowds is unnecessary, and immobilizing the arm is not advised; gentle movement aids recovery.
The male client is considering a vasectomy for birth control. Which information should the nurse teach the client?
- A. Instruct the client to use hot packs to relieve scrotal edema after the surgery.
- B. Tell the client to wear loose-fitting boxer underwear after the surgery.
- C. Explain initially an alternate form of birth control will be required.
- D. Discuss potency will be diminished about 20% after a vasectomy.
Correct Answer: C
Rationale: Alternate contraception is needed post-vasectomy until sperm clearance (confirmed by semen analysis). Hot packs worsen edema, boxer underwear is nonspecific, and potency is unaffected.
If the client reports all of the following data, which factor is most likely contributing to the bleeding?
- A. The client has been taking an oral contraceptive for 2 months.
- B. The client has just changed employment and is under unusual stress.
- C. The client's sexual partner has a sexually transmitted infection.
- D. The client has been using a vibrator to elicit sexual arousal.
Correct Answer: A
Rationale: Breakthrough bleeding is a common side effect of oral contraceptives, especially in the first few months, making it the most likely cause of vaginal bleeding outside expected menses.
Which comment indicates that the client lacks a clear understanding of syphilis?
- A. I need to take my antibiotic for several months.
- B. My sex partner should be tested for the disease.
- C. Syphilitic lesions may be present in my partner's vagina.
- D. One infection provides lifelong immunity.
Correct Answer: D
Rationale: Syphilis does not confer lifelong immunity; reinfection is possible, indicating a misunderstanding by the client.
Which nursing diagnosis is most appropriate for the nurse to add to the client's care plan at this time?
- A. Risk for ineffective airway clearance
- B. Risk for imbalanced nutrition
- C. Ineffective coping
- D. Impaired verbal communication
Correct Answer: A
Rationale: General anesthesia and abdominal surgery increase the risk of respiratory complications, making ineffective airway clearance a priority diagnosis.