Nokea
What is the first exercise that should be performed by a client who had a mastectomy?
- A. Walking the hand up the wall
- B. Sweeping the floor
- C. Combing her hair
- D. Squeezing a ball
Correct Answer: D
Rationale: The correct answer is D: Squeezing a ball. The first exercise that should be done by a client with a mastectomy is squeezing a ball. This helps in regaining strength and mobility in the affected area. Choices A, B, and C are incorrect as they are not typically the initial exercises recommended post-mastectomy. Walking the hand up the wall, sweeping the floor, and combing hair are activities that may be introduced later in the rehabilitation process.
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Social support systems include all of the following except:
- A. call-in help lines
- B. emotional assistance provided by others
- C. community support groups
- D. use of coping skills and verbalization for anger management
Correct Answer: D
Rationale: Social support systems involve external sources of support like call-in help lines, emotional assistance from others, and community support groups. These external resources provide individuals with assistance and comfort. Coping skills and verbalization for anger management are personal strategies that individuals use to manage emotions internally. While these skills can be beneficial, they are not considered part of external social support systems.
The nurse is caring for a client with cerebral palsy. The nurse should provide frequent rest periods because:
- A. Grimacing and writhing movements decrease with relaxation and rest.
- B. Hypoactive deep tendon reflexes become more active with rest.
- C. Stretch reflexes are increased with rest.
- D. Fine motor movements are improved.
Correct Answer: A
Rationale: Frequent rest periods help to relax tense muscles and preserve energy in clients with cerebral palsy. This can lead to a decrease in grimacing and writhing movements, as relaxation and rest help to alleviate muscle tension. Choices B, C, and D are incorrect because they provide inaccurate information. Hypoactive deep tendon reflexes do not become more active with rest; stretch reflexes are not increased with rest in cerebral palsy patients, and fine motor movements are not necessarily improved solely by rest.
Which laboratory test would be the least effective in diagnosing a myocardial infarction?
- A. AST
- B. Troponin
- C. CK-MB
- D. Myoglobin
Correct Answer: A
Rationale: AST, choice A, would be the least effective in diagnosing a myocardial infarction as it is not specific for this condition. Troponin, CK-MB, and myoglobin (choices B, C, and D) are more specific markers for myocardial infarction. Troponin is considered the gold standard due to its cardiac specificity. CK-MB is also specific to the heart, and its isoenzyme levels elevate post-heart damage. Myoglobin, although elevated in myocardial infarction, is not as specific as troponin and CK-MB and can also increase in conditions like burns and muscle trauma. Therefore, AST is the least effective choice for diagnosing a myocardial infarction.
If the client is receiving peritoneal dialysis and the dialysate returns cloudy, what should the nurse do?
- A. Document the finding
- B. Send a specimen to the lab
- C. Strain the dialysate
- D. Obtain a complete blood count
Correct Answer: B
Rationale: When the dialysate returns cloudy, it could indicate the presence of infection, and sending a specimen to the lab for evaluation is crucial to determine the cause. Documenting the finding alone, as in choice A, may not provide enough information for proper intervention. Straining the dialysate, as in choice C, is not a standard practice and may not help identify the underlying issue. Obtaining a complete blood count, as in choice D, is not directly related to addressing cloudiness in the dialysate. However, the healthcare provider might order a white blood cell count to assess for infection.
Which of the following statements is correct regarding rape?
- A. Most rapes go unreported.
- B. Legally, a woman can be raped by her spouse.
- C. Prosecuting and convicting for rape can be challenging.
- D. Rape can occur in different locations.
Correct Answer: B
Rationale: The correct statement is that legally, a woman can be raped by her spouse. Rape is defined as sexual intercourse against someone's will, and it can occur between any two persons regardless of their relationship, including spouses. Choice A is incorrect as most rapes are not reported due to various reasons like fear, shame, or distrust in the legal system. Choice C is incorrect as prosecuting and convicting for rape can be challenging due to factors like lack of evidence, societal biases, and victim blaming. Choice D is incorrect as the most common location of rape is not necessarily the victim's own home; it can happen in various settings such as public places, workplaces, or social gatherings.