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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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The client is scheduled for a pericentesis. Which instruction should be given to the client before the exam?
- A. "You will need to lie flat during the exam."?
- B. "You need to empty your bladder before the procedure."?
- C. "You will be asleep during the procedure."?
- D. "The doctor will inject a medication to treat your illness during the procedure."?
Correct Answer: B
Rationale: The client scheduled for a pericentesis should be instructed to empty the bladder to prevent the risk of bladder puncture when the needle is inserted. A pericentesis involves removing fluid from the peritoneal cavity. The client is typically positioned sitting up or leaning over a table, making answer A incorrect. During a pericentesis, the client is usually awake, so answer C is incorrect. Medications are not commonly injected into the peritoneal cavity during this procedure, making answer D incorrect. However, it's important to note that the administration of medications during the procedure could vary based on specific circumstances.
A 26-year-old single woman is knocked down and robbed while walking her dog one evening. Three months later, she presents at the crisis clinic, stating that she cannot put this experience out of her mind. She complains of nightmares, extreme fear of being outside or alone, and difficulty eating and sleeping. What is the best response by the nurse?
- A. "I will ask the physician to prescribe medication for you."?
- B. "That must have been a very difficult and frightening experience. It might be helpful to talk about it."?
- C. "In the future, you might walk your dog in a more populated area or hire someone else to take over this task."?
- D. "Have you thought of moving to a safer neighborhood?"?
Correct Answer: B
Rationale: Choice B is the best response as it provides empathy and encourages the client to talk about her experience, which can be therapeutic. This approach validates the client's feelings and offers support. By acknowledging the difficulty and fear experienced by the client, the nurse opens the door for the client to express her emotions and begin the process of coping with the trauma. Choices A, C, and D do not address the emotional impact of the traumatic event or provide an opportunity for the client to express her feelings and concerns. Choice A immediately jumps to medication without exploring other supportive interventions. Choice C focuses on practical solutions without addressing the client's emotional needs. Choice D suggests a drastic solution without considering the client's emotional state or preferences.
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.
A nurse provides information about feeding to the mother of a 6-month-old infant. Which statement by the mother indicates an understanding of the information?
- A. Meats are really important for iron, and I should start feeding meats to my infant right away.
- B. Egg white should not be given to my infant because of the risk for an allergy.
- C. I can mix the food in my infant's bottle if he won't eat it.
- D. Fluoride supplementation is not necessary until permanent teeth come in.
Correct Answer: B
Rationale: The correct answer is B: 'Egg white should not be given to my infant because of the risk for an allergy.' Egg white, even in small quantities, is not recommended for infants until the end of the first year of life due to its common allergenic potential. Choice A is incorrect because while meats are important for iron, they are not typically introduced to infants until around 6-8 months. Choice C is incorrect because food should never be mixed with formula in the bottle as it may lead to feeding difficulties and inaccurate monitoring of intake. Choice D is incorrect because fluoride supplementation may be required around 6 months depending on the infant's fluoride intake from water. Introducing solid foods like rice cereal, fruits, or vegetables is usually done around 5-6 months, following healthcare provider recommendations.
The nurse is making assignments for the day. Which client should be assigned to the nursing assistant?
- A. A client with Alzheimer's disease
- B. A client with pneumonia
- C. A client with appendicitis
- D. A client with thrombophlebitis
Correct Answer: A
Rationale: The client with Alzheimer's disease is the most stable among the clients listed and can be appropriately assigned to the nursing assistant. Nursing assistants are capable of providing care such as feeding and assisting with activities of daily living for individuals with Alzheimer's disease. Clients with pneumonia, appendicitis, and thrombophlebitis are less stable and necessitate the expertise of a registered nurse for accurate assessment and interventions. Therefore, the nursing assistant can effectively care for the client with Alzheimer's disease while ensuring that the other clients receive the necessary level of care from a registered nurse.