Nokea
What factors should the nurse consider for teaching a child about his or her disease and related health care measures?
- A. A child rarely forms misconceptions.
- B. The older the child, the shorter the attention span.
- C. A child's imagination may create greater fear than the truth.
- D. A child may regress developmentally in a situation of illness.
- E. It is not necessary to assess the child's knowledge before teaching.
- F. A child may better manage uncomfortable information through role-playing.
Correct Answer: C,D,F
Rationale: For children, the teaching-learning process may be fundamentally different from that used for adults, and the nurse needs to adjust the complexity and volume of information based on the child's age and cognitive level. The factors that need to be addressed when teaching children include the following: Trust is essential to a therapeutic relationship; in general, the younger the child, the shorter the attention span; assessing the child's knowledge is important because children are exposed to various levels of information about health care; children form misconceptions easily, and a child's imagination may create greater fear than the truth; a child may regress developmentally in a situation of illness; and a child may better manage uncomfortable information through role-playing.
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A client is preparing to undergo a cystoscopy for stones. Which of the following statements indicates that the client understands the procedure?
- A. I better drink a lot of fluid now because I won't be able to after the test.
- B. I will probably see a little blood when I urinate.
- C. I will be able to go home after 3 days in the hospital.
- D. I won't need any pain medicine; this probably will not hurt.
Correct Answer: B
Rationale: The correct answer is, 'I will probably see a little blood when I urinate.' During a cystoscopy, a scope is inserted into the client's bladder to inspect structures or remove objects like stones. This procedure is usually performed under local or general anesthesia. It is common for clients to experience a small amount of blood in their urine (hematuria) or have pink-colored urine after the procedure. The other choices are incorrect because drinking a lot of fluid before the test, staying in the hospital for 3 days, and assuming no pain will be experienced are not accurate statements related to a cystoscopy procedure.
Mr. Y had surgery two days ago and is recovering on the surgical unit of the hospital. Just before lunch, he develops chest pain and difficulties with breathing. His respiratory rate is 32/minute, his temperature is 100.8°F, and he has rales on auscultation. Which of the following nursing interventions is most appropriate in this situation?
- A. Place the client in the Trendelenburg position
- B. Contact the physician for an order for antibiotics
- C. Administer oxygen therapy
- D. Decrease his IV rate
Correct Answer: C
Rationale: Chest pain, dyspnea, tachypnea, mild fever, and rales or crackles on auscultation in a client who had surgery 2 days ago may be indicative of a pulmonary embolism. The nurse should administer oxygen to address his breathing and assist him to a comfortable position to facilitate better oxygenation before contacting the physician. Placing the client in the Trendelenburg position is not recommended in this situation as it may worsen a potential pulmonary embolism by increasing venous return. Contacting the physician for antibiotics is not the priority as the immediate concern is addressing the breathing difficulty. Decreasing the IV rate is not indicated in this situation where the client is experiencing respiratory distress and needs oxygen therapy.
The nurse is caring for a client with a non-rebreather mask. Which is the priority nursing action when caring for this client?
- A. maintain the mask snugly on the face
- B. adjust flow rate to keep the reservoir bag inflated
- C. ensure that the reservoir bag is not kinked or twisted
- D. ensure that valves open during expiration and close on inhalation
Correct Answer: B
Rationale: Adjusting the flow rate to keep the reservoir bag inflated ensures adequate oxygen delivery, the primary goal of a non-rebreather mask.
Two basic but important risk factors for testicular cancer are which of the following?
- A. Race
- B. Age
- C. Marital status
- D. Number of children
Correct Answer: A,B
Rationale: Two basic but important risk factors for testicular cancer are race and age. The incidence of testicular cancer is four times higher among white males than black males. It is the most common type of cancer to occur in males between the ages of 15 and 34 years. Other risk factors include a history of an undescended testis and a family history of testicular cancer. Marital status and the number of children are not risk factors for testicular cancer.
A client returns from surgery after having a colon resection. The nurse is performing an assessment and notes the wound edges have separated. This condition is called:
- A. Evisceration
- B. Hematoma
- C. Dehiscence
- D. Granulation
Correct Answer: C
Rationale: Wound dehiscence occurs when the edges of a wound pull apart. The condition may occur following a surgical procedure if the sutures were deficient. Wound dehiscence may also occur following a wound infection or in cases where a client significantly stretches or overuses the associated tissues. Evisceration refers to the protrusion of internal organs through an open wound. Hematoma is a localized collection of blood outside the blood vessels. Granulation is the formation of new connective tissue and tiny blood vessels on the surface of a wound during the healing process.