Nokea
When the client asks how this condition will affect him sexually, which response by the nurse is most appropriate?
- A. It most likely will have little effect on your masculinity.
- B. It means that you will probably be impotent.
- C. You may notice that your breasts will enlarge later.
- D. Your sex drive will not be like that of other boys.
Correct Answer: A
Rationale: An undescended testicle, if corrected, typically has minimal impact on sexual function or masculinity, especially if addressed early.
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The nurse is formulating a care plan for a client post-abdominal hysterectomy. Which nursing diagnosis is appropriate for the client who has developed a complication?
- A. Potential for urinary retention.
- B. Potential for nerve damage.
- C. Potential for intestinal obstruction.
- D. Potential for fluid imbalance.
Correct Answer: C
Rationale: Intestinal obstruction is a common complication post-abdominal hysterectomy due to adhesions or ileus. Urinary retention and fluid imbalance are risks but less specific, and nerve damage is rare.
The female client has a mother who died from ovarian cancer and a sister diagnosed with ovarian cancer. Which recommendations should the nurse make regarding early detection of ovarian cancer?
- A. The client should consider having a prophylactic bilateral oophorectomy.
- B. The client should have a transvaginal ultrasound and a CA-125 laboratory test every six (6) months.
- C. The client should have yearly magnetic resonance imaging (MRI) scans.
- D. The client should have a biannual gynecological examination with flexible sigmoidoscopy.
Correct Answer: B
Rationale: High familial risk warrants transvaginal ultrasound and CA-125 every 6 months for early detection. Prophylactic oophorectomy is a personal choice, MRI is not standard, and sigmoidoscopy is unrelated.
The client has undergone a wedge resection for cancer of the left breast. Which discharge instruction should the nurse teach?
- A. Don't lift more than five (5) pounds with the left hand until released by the HCP.
- B. The cancer has been totally removed and no follow-up therapy will be required.
- C. The client should empty the Hemovac drain about every 12 hours.
- D. The client should arrange an appointment with a plastic surgeon for reconstruction.
Correct Answer: A
Rationale: Limiting lifting with the affected arm prevents strain and lymphedema risk post-wedge resection. Claiming cancer is fully removed is misleading, Hemovac drains are uncommon in lumpectomy, and reconstruction is not universally needed.
The client is diagnosed with benign uterine fibroid tumors. Which question should the nurse ask to determine if the client is experiencing a complication?
- A. How many periods have you missed?'
- B. Do you get short of breath easily?'
- C. How many times have you been pregnant?'
- D. Where is the location of the pain you are having?'
Correct Answer: D
Rationale: Pain location helps identify complications like fibroid degeneration or pressure on organs. Missed periods are common, shortness of breath is unrelated, and pregnancy history is less relevant.
The client who had a right modified radical mastectomy four (4) years before is being admitted for a cardiac work-up for chest pain. Which intervention is most important for the nurse to implement?
- A. Determine when the client had chemotherapy last.
- B. Ask the client if she received Adriamycin, an antineoplastic agent.
- C. Post a message at the HOB for staff not to use the right arm for venipunctures or BPs.
- D. Examine the chest wall for cancer sites.
Correct Answer: C
Rationale: Post-mastectomy, the affected arm is at risk for lymphedema; avoiding venipuncture or BP on that arm is critical. Chemotherapy history is less urgent, Adriamycin relates to cardiotoxicity but not immediate care, and chest wall exam is secondary.