Nokea
When teaching an adolescent male client about testicular self-examination, which instruction should the nurse include?
- A. Have examination after a warm bath or shower.
- B. Report any difference in the size of your testicles to the physician.
- C. Malignant lumps are usually located on the front side of the testicles.
- D. Both testicles should be examined simultaneously to detect differences.
Correct Answer: A
Rationale: Performing testicular self-examination after a warm bath or shower relaxes the scrotum, making it easier to detect abnormalities, a key instruction for effective screening.
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Which nursing instruction is correct for the parents of a child who has a vitamin D deficiency?
- A. Give the child cod liver oil daily.
- B. Give the child orange juice daily.
- C. Apply sunblock to the child before sun exposure.
- D. Keep the child indoors during daylight hours.
Correct Answer: A
Rationale: Cod liver oil is a rich source of vitamin D, essential for correcting vitamin D deficiency and supporting bone health.
The nurse meets the frantic father at an ED door. He says he just delivered his wife’s full-term newborn in the car when the temperature outside is only 10°F (—12.2°C). In response to the cold environment,the nurse knows that the infant’s body will immediately begin to produce heat by which mechanism?
- A. Shivering
- B. Metabolizing body fat
- C. Dilating surface blood vessels
- D. Decreasing flexion of the extremities
Correct Answer: B
Rationale: When skin receptors of full-term newborns perceive a drop in environmental temperature the sympathetic nervous system is stimulated. This in turn stimulates metabolism of brown fat thus producing heat that is transferred to the peripheral circulation. Shivering is rarely seen in newborns and it does little to produce heat. Newborns conserve heat by constricting not dilating blood vessels. Decreasing flexion promotes heat loss by exposing more skin surface.
The nurse advises the parents that the child is due to receive which of the following immunization boosters?
- A. Haemophilus influenzae type b (Hib)
- B. Polio
- C. Smallpox
- D. Tetanus
Correct Answer: D
Rationale: A 14-year-old is due for a tetanus-diphtheria-pertussis (Tdap) booster, typically recommended at 11-12 years if not received since age 6, to maintain immunity.
Which information about methamphetamine use is most accurate and important for the parents to know?
- A. Methamphetamines are tried by most adolescents and cause no harm.
- B. Methamphetamines are known to lead to addiction.
- C. Methamphetamines are a central nervous system depressant.
- D. Methamphetamines are harmful only if taken intravenously.
Correct Answer: B
Rationale: Methamphetamines are highly addictive stimulants, and informing parents about the risk of addiction is critical to understanding the severity of the adolescent's behavior.
Which intervention is most appropriate for a child with a musculoskeletal disability using a wheelchair?
- A. Encourage competitive sports to build strength.
- B. Provide a firm mattress to prevent bedsores.
- C. Teach the child to avoid all physical activity.
- D. Limit the child's interaction with peers.
Correct Answer: B
Rationale: A firm mattress helps distribute weight evenly, reducing the risk of pressure ulcers in a child with limited mobility due to a musculoskeletal disability.