Nokea
When the nurse does a physical assessment of this client, which technique is best for determining the extent of the prolapse?
- A. Examine the perineum when the client rolls from side to side.
- B. Examine the perineum as the client stands and bears down.
- C. Examine the perineum with the client in a dorsal recumbent position.
- D. Examine the perineum with a lubricated speculum and flashlight.
Correct Answer: B
Rationale: Standing and bearing down makes a prolapsed uterus more visible, allowing accurate assessment of its extent.
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Which question is most important to ask to ensure valid analysis of the vaginal specimen?
- A. How did you last have sexual intercourse?
- B. How old were you when you had your first pregnancy?
- C. What was the date of your last menstrual period?
- D. Have you ever used oral contraceptives?
Correct Answer: C
Rationale: The date of the last menstrual period is critical to interpret vaginal specimen results, as the menstrual cycle phase affects cervical and vaginal cell characteristics.
Which assessment findings recorded by the nurse indicate high risk factors for developing breast cancer? Select all that apply.
- A. The client began menstruating before age 12.
- B. The client had three full-term pregnancies.
- C. The client has a very large breast.
- D. The client has had radiation treatment to the chest.
- E. The client has had breast implants.
Correct Answer: A,D
Rationale: Early menarche (before age 12) and chest radiation exposure are established risk factors for breast cancer due to prolonged estrogen exposure and DNA damage, respectively. Multiple pregnancies reduce risk, and breast size or implants are not significant risk factors.
The client is diagnosed with metastatic prostate cancer to the bones. Which nursing intervention should the nurse implement?
- A. Prepare for a transurethral resection of the prostate.
- B. Keep the foot of the bed elevated at all times.
- C. Place the client on a scheduled bowel regimen.
- D. Discuss the client’s altered sexual functioning.
Correct Answer: C
Rationale: Bone metastasis increases constipation risk (e.g., from analgesics); a bowel regimen prevents complications. TURP is for obstruction, bed elevation is irrelevant, and sexual function is secondary.
The 24-year-old female client presents to the clinic with lower abdominal pain on the left side she rates as a '9' on a 1-to-10 scale. Which diagnostic procedure should the nurse prepare the client for?
- A. A computed tomography scan.
- B. A lumbar puncture.
- C. An appendectomy.
- D. A pelvic sonogram.
Correct Answer: D
Rationale: Severe left-sided pelvic pain suggests ovarian pathology (e.g., cyst, torsion); a pelvic sonogram is the initial diagnostic tool. CT is less specific, lumbar puncture is irrelevant, and appendectomy is premature.
What special instruction concerning the technique for taking vital signs is most important when assigning this task to a nursing assistant?
- A. Count the client's respirations while he is resting.
- B. Assess the client's pulse at the radial site.
- C. Take the client's blood pressure with an electronic machine.
- D. Avoid taking a rectal temperature.
Correct Answer: D
Rationale: Avoiding rectal temperature measurement prevents trauma or infection in a client with a suprapubic prostatectomy and catheters.