Nokea
What intervention should the nurse implement for a client diagnosed with a rectocele?
- A. Limit oral intake to decrease voiding.
- B. Encourage a low-residue diet.
- C. Administer a stool softener daily.
- D. Arrange for the client to take sitz baths.
Correct Answer: C
Rationale: Stool softeners prevent straining during bowel movements, reducing rectocele pressure. Limiting intake is inappropriate, low-residue diets increase constipation risk, and sitz baths are less specific.
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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.
The nurse correctly informs the client that the breast self-examination (BSE) technique involves palpating each breast moving in small concentric circles, following imaginary spokes in a wheel, or moving in rows from superior to inferior stress of the breast. Besides the breast, which other body area is essential to palpate?
- A. The axillae
- B. The sternum
- C. The clavicles
- D. The ribs
Correct Answer: A
Rationale: The axillae (armpits) contain lymph nodes that drain the breast tissue, and palpating this area is essential to detect any abnormal lymph node enlargement, which could indicate breast pathology.
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.
When the nurse provides the client with pretest instructions, which statement is most correct?
- A. You'll need to fast from midnight the night before the test.
- B. You'll need to empty your bladder just before the test begins.
- C. You'll need to consume at least a quart of water an hour before the test.
- D. You'll need to self-administer an enema 1 hour before the test.
Correct Answer: C
Rationale: A full bladder is required for a transabdominal prostate sonogram to provide a clear acoustic window for imaging.
The client has had an exploratory laparotomy to remove an ovarian tumor. The pathology report classifies the tumor as a 'low malignancy potential' (LMP) tumor. Which statement explains the scientific rationale for this pathology report?
- A. The client does not have cancer but will need adjuvant therapy.
- B. The client would have developed cancer if the tumor had not been removed.
- C. These borderline tumors resemble ovarian cancer but have better outcomes.
- D. The client has a very poor prognosis and has less than six (6) months to live.
Correct Answer: C
Rationale: LMP tumors (borderline ovarian tumors) have malignant features but lower metastatic potential, with better prognosis than invasive ovarian cancer. They are cancerous, not precancerous, and do not inherently require adjuvant therapy or indicate poor prognosis.