Nokea
Which client has the highest risk of ovarian cancer?
- A. 30-year old woman taking contraceptives
- B. 45-year old woman who has never been pregnant
- C. 40-year old woman with three children
- D. 36-year old woman who had her first child at age 22
Correct Answer: B
Rationale: The correct answer is B: 45-year old woman who has never been pregnant. The risk of ovarian cancer increases with age and nulliparity (never having been pregnant) is a significant risk factor. The older a woman gets without having been pregnant, the higher her risk of developing ovarian cancer. The other choices do not have as high of a risk factor for ovarian cancer. Choice A, a 30-year old woman taking contraceptives, actually reduces the risk of ovarian cancer. Choice C, a 40-year old woman with three children, and choice D, a 36-year old woman who had her first child at age 22, both have lower risk factors compared to choice B.
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Usually, how does the patient behave after his seizure has subsided?
- A. Most comfortable walking and moving about
- B. Sleeps for a period of time
- C. Becomes restless and agitated
- D. Say he is thirsty and hungry
Correct Answer: B
Rationale: The correct answer is B: Sleeps for a period of time. After a seizure, the brain and body experience fatigue and exhaustion. It is common for the patient to feel drowsy and require rest to recover. This post-ictal state is characterized by sleepiness and confusion. The other choices are incorrect because typically, after a seizure, the patient is not most comfortable walking and moving about (A), does not become restless and agitated (C), and may not immediately express thirst and hunger (D). It is important to ensure the patient is in a safe environment and allow them to rest after a seizure episode.
A 78 year old male has been working on his lawn for two days, although the temperature has been above 90 degree F. he has been on thiazide diuretics for hypertension. His lab values are K 3.7 mEq/L, Na 129 mEq/L, Ca 9 mg/dl, and Cl 95 mEq/L. What would be a priority action for this man?
- A. Make sure he drinks 8 glasses of water a day.
- B. Monitor for fatigue, muscle weakness, restlessness, and flushed skin
- C. Look for signs of hyperchloremia
- D. Observe for neurologic changes
Correct Answer: B
Rationale: The correct answer is B: Monitor for fatigue, muscle weakness, restlessness, and flushed skin. The patient is at risk for dehydration due to the combination of high temperature, age, and thiazide diuretic use. Thiazide diuretics can lead to electrolyte imbalances, including hypokalemia, which can cause symptoms such as muscle weakness and fatigue. Monitoring for signs of dehydration and electrolyte imbalances is crucial in this scenario to prevent complications.
A: Making sure he drinks 8 glasses of water a day is not the priority as he is already at risk for dehydration and electrolyte imbalances.
C: Hyperchloremia is not a common concern in this scenario based on the given lab values.
D: Neurologic changes may occur in severe cases of electrolyte imbalances but monitoring for physical symptoms such as fatigue and muscle weakness is more relevant at this stage.
A nurse is evaluating the goal of acceptance of body image in a young teenage girl. Which statement made by the patient is the best indicator of progress toward the goal?
- A. “I’m worried about what those other girls will think of me.”
- B. “I can’t wear that color. It makes my hips stick out.”
- C. “I’ll wear the blue dress. It matches my eyes.”
- D. “I will go to the pool next summer.”
Correct Answer: C
Rationale: The correct answer is C because it shows a positive self-perception and self-acceptance. By choosing the dress based on how it complements her eyes, the patient demonstrates a focus on her own preferences and self-image rather than external validation or criticism. This indicates progress towards accepting her body image.
A: Choice A indicates concern about others' opinions, which shows a lack of self-assurance and reliance on external validation.
B: Choice B reflects negative body image and self-criticism, indicating a lack of acceptance.
D: Choice D is focused on a future event, suggesting avoidance or delay in addressing the current body image issues.
The nurse, in assessing the adequacy of a client's fluid replacement during the first 2 to 3 days following full- thickness burns to the trunk and right thigh, would be aware that the most significant data would be obtained from recording
- A. Weights every day .
- B. Blood pressure every 15 minutes
- C. Urinary output every hour
- D. Extent of peripheral edema every 4 hours
Correct Answer: C
Rationale: The correct answer is C: Urinary output every hour. This is because assessing urinary output is crucial for monitoring fluid balance in burn patients. Adequate urine output indicates proper fluid replacement, while decreased output may indicate dehydration. Recording weights daily (choice A) may be important but not as immediate and specific as urinary output. Blood pressure every 15 minutes (choice B) is too frequent and not directly related to fluid replacement in this context. Monitoring peripheral edema every 4 hours (choice D) is not as reliable as urinary output for assessing fluid status.
The nurse is interviewing a patient with a hearing deficit. Which area should the nurse use to conduct this interview?
- A. The patient’s room with the door closed
- B. The waiting area with the television turned off
- C. The patient’s room before administration of pain medication
- D. The waiting room while the occupational therapist is working on leg exercises
Correct Answer: B
Rationale: The correct answer is B: The waiting area with the television turned off. This choice eliminates potential distractions, allowing the patient with a hearing deficit to focus on the interview. Noise from the television can interfere with communication. Other choices are incorrect because: A) The closed door may block out external noise, but the patient's room could still have distractions. C) Administering pain medication can affect the patient's alertness and ability to communicate effectively. D) The waiting room with occupational therapy activities can be noisy and distracting. Conducting the interview in a quiet waiting area ensures optimal communication and understanding.