Nokea
To do an effective breast self-examination, when should the woman examine her breasts?
- A. During the fourth to the seventh menstrual cycle day
- B. Every other month
- C. While standing up
- D. 1 week before the menstrual cycle
Correct Answer: A
Rationale: The correct answer is A: During the fourth to the seventh menstrual cycle day. This is because breasts are least likely to be swollen or tender during this time, allowing for a more accurate examination. Choice B is incorrect as regular monthly examinations are recommended. Choice C can be done while standing up or lying down. Choice D is incorrect as breasts may be more tender and swollen closer to the menstrual cycle, making it harder to detect abnormalities.
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Which assessment tools can be used to assess the cardiac system (select all that apply)?
- A. Watch
- B. Stethoscope
- C. Ophthalmoscope
- D. Percussion hammer
Correct Answer: D
Rationale: The correct answers are 'Watch,' 'Stethoscope,' 'Percussion hammer,' and 'Blood pressure cuff.' These tools aid in evaluating heart rate, rhythm, sounds, and vascular status.
What symptoms would a nurse suspect in a client with acoustic neuroma?
- A. Altered facial sensation
- B. Vertigo only when standing
- C. Tinnitus in the unaffected ear
- D. Impaired facial movement when smiling
Correct Answer: A
Rationale: Acoustic neuromas often affect cranial nerve VII, leading to altered facial sensation.
The physician has written orders for the client with Excess Fluid Volume. The client's morning assessment includes bounding peripheral pulses, weight gain of 2 pounds, pitting ankle edema, and moist crackles bilaterally. Which order takes priority at this time?
- A. Weigh client every morning
- B. Maintain accurate intake and output
- C. Restrict fluid to 1500 mL per day
- D. Administer furosemide (Lasix) 40 mg IV push
Correct Answer: D
Rationale: The correct answer is D: Administer furosemide (Lasix) 40 mg IV push. This is the priority because the client is showing signs of fluid volume excess, such as weight gain, pitting edema, and crackles, which indicate fluid overload in the lungs. Furosemide is a loop diuretic that helps to remove excess fluid from the body quickly, making it crucial in managing excess fluid volume in this situation. Weighing the client daily (A) is important but not as urgent as addressing the immediate symptoms of fluid overload. Maintaining accurate intake and output (B) is essential for overall fluid balance but does not address the immediate excess fluid volume. Fluid restriction (C) may be needed in the long term, but immediate intervention with furosemide is necessary to prevent worsening of symptoms and potential complications.
For which nursing diagnoses or collaborative problems common in postoperative patients has ambulation been found to be an appropriate intervention (select all that apply)?
- A. Impaired skin integrity related to incision
- B. Impaired mobility related to decreased muscle strength
- C. Risk for aspiration related to decreased muscle strength
- D. Ineffective airway clearance related to decreased respiratory excursion
Correct Answer: D
Rationale: Ambulation addresses multiple postoperative issues, including mobility, respiratory function, constipation, and thromboembolism prevention.
If a client denies having a hearing impairment, which question would encourage them to respond?
- A. Do you always ask people to repeat questions? If so, do you think that you have a hearing problem?
- B. Are you cupping your ear for a reason? Do you have trouble hearing?
- C. Both A and B
- D. Neither A nor B
Correct Answer: C
Rationale: Asking open-ended questions increases the likelihood of acknowledgment and discussion of the issue.