Nokea
When teaching the guardian of a 12-year-old male client about manifestations of puberty, which of the following physical changes typically occurs first?
- A. Appearance of downy hair on the upper lip
- B. Hair growth in the axillae
- C. Enlargement of the testes and scrotum
- D. Deepening of the voice
Correct Answer: C
Rationale: During puberty in males, the first physical change that typically occurs is the enlargement of the testes and scrotum. This change is due to increased production of testosterone, which stimulates growth and development of the genital organs. The appearance of downy hair on the upper lip (Choice A) and hair growth in the axillae (Choice B) usually follow the enlargement of the testes and scrotum. Deepening of the voice (Choice D) is a later stage change that occurs during puberty as the larynx (voice box) grows and the vocal cords lengthen and thicken.
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A client has a closed wound drainage system. Which of the following actions should the nurse take?
- A. Avoid pressing the container down to create a vacuum
- B. Wear sterile gloves while handling the drainage system
- C. Reset the container with the drainage port closed
- D. Maintain the drain in a dependent position to facilitate drainage
Correct Answer: D
Rationale: In a closed wound drainage system, it is essential to maintain the drain in a dependent position to allow for proper drainage. Gravity aids in the flow of drainage, preventing fluid backflow or pooling. Avoiding pressing the container down to create a vacuum (Choice A) is crucial as it can lead to complications in the system. Wearing sterile gloves (Choice B) is important for infection control when handling the drainage system. Resetting the container with the drainage port closed (Choice C) is incorrect as it can cause spillage and contamination of the surrounding area.
A nurse in a health clinic is caring for a 20-year-old client who tells the nurse that their last physical exam was in high school. Which of the following health screenings should the nurse expect the provider to perform for this client?
- A. Testicular examination
- B. Blood glucose
- C. Fecal occult blood
- D. Prostate-specific antigen
Correct Answer: A
Rationale: A testicular examination is appropriate for a 20-year-old male to screen for testicular cancer, which is more common in younger age groups. Testicular cancer is most frequently diagnosed in individuals between the ages of 15 and 40. Blood glucose screening is typically recommended for older individuals or those at risk for diabetes. Fecal occult blood testing is used for colorectal cancer screening, usually starting at age 50. Prostate-specific antigen testing is commonly considered for prostate cancer screening in older males, typically around age 50. Therefore, the most appropriate screening for the 20-year-old client is the testicular examination.
The nurse is caring for a client diagnosed with hypothyroidism. Which finding should the nurse expect to observe?
- A. Weight gain
- B. Heat intolerance
- C. Increased appetite
- D. Frequent diarrhea
Correct Answer: A
Rationale: The correct answer is weight gain. In hypothyroidism, there is a decrease in metabolic rate, which can lead to weight gain. Heat intolerance (choice B) is more commonly associated with hyperthyroidism. Increased appetite (choice C) and frequent diarrhea (choice D) are not typical findings in hypothyroidism. Therefore, choices B, C, and D are incorrect.
The healthcare provider is assessing an immobile patient for deep vein thromboses (DVTs). Which action will the healthcare provider take?
- A. Remove elastic stockings every 4 hours.
- B. Measure the calf circumference of both legs.
- C. Lightly rub the lower leg for redness and tenderness.
- D. Dorsiflex the foot while assessing for patient discomfort.
Correct Answer: B
Rationale: The correct action when assessing an immobile patient for deep vein thromboses (DVTs) is to measure the calf circumference of both legs. This helps in detecting swelling or changes that may indicate the presence of a DVT. Removing elastic stockings every 4 hours (Choice A) is not necessary and can disrupt circulation. Lightly rubbing the lower leg for redness and tenderness (Choice C) can potentially dislodge a clot if present. Dorsiflexing the foot while assessing for patient discomfort (Choice D) is not a specific assessment for DVT and may not provide relevant information in this context.
A healthcare provider is delegating client care to assistive personnel. Which of the following tasks should the healthcare provider delegate?
- A. Evaluating healing of an incision
- B. Inserting an NG Tube
- C. Performing a simple dressing change
- D. Changing IV tubing
Correct Answer: C
Rationale: The correct task that a healthcare provider should delegate to assistive personnel is performing a simple dressing change. Assistive personnel are trained and competent in performing basic wound care activities like simple dressing changes. Evaluating the healing of an incision requires clinical judgment and assessment skills that are typically performed by licensed healthcare professionals, such as nurses or physicians. Inserting an NG tube and changing IV tubing involve invasive procedures that require specialized training and skills, making them tasks that should be performed by licensed healthcare providers rather than assistive personnel.