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Which of the ff. statements, if made by a patient with hypertension, indicates to a nurse a need for more teaching?
- A. "High BP may affect the kidneys and eyes."
- B. "Most people with hypertension watch their diet."
- C. "Medication will no longer be needed when I feel better."
- D. "Many people do not know when their BP is high."
Correct Answer: C
Rationale: Option C, "Medication will no longer be needed when I feel better," indicates a need for more teaching by the nurse. This statement shows a misunderstanding regarding hypertension management. Hypertension is a chronic condition that often requires long-term treatment with medications even if the patient feels better. The patient should be educated on the importance of continued medication adherence to effectively manage their hypertension and prevent complications. Options A, B, and D demonstrate understanding of hypertension and its management, indicating that more teaching is not necessary in those areas.
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Which of the following is MOST likely considered a risk factor for extraneural metastasis in primary brain tumors?
- A. age less than 10 year
- B. female gender
- C. ventriculoperitoneal (VP) shunt insertion
- D. supratentorial tumor
Correct Answer: A
Rationale: Younger age is a significant risk factor for extraneural metastasis in pediatric brain tumors.
HIV antibody testing procedures using a finger stick or venipuncture to obtain whole blood, plasma, or serum, and tests using oral fluid were approved. All the following regarding this test are true EXCEPT
- A. they are simple and accurate as to render the likelihood of an erroneous result by the user negligible
- B. a positive result does not need confirmation by Western blot analysis or immunofluorescence assay
- C. they allow women who have not been tested or are unaware of their HIV status to reduce the risk of mother-to-child transmission of antiretroviral therapy implementation
- D. they significantly reduce the risk of mother-to-child transmission
Correct Answer: B
Rationale: A positive result from rapid HIV tests still requires confirmation with more specific tests like Western blot or immunofluorescence assay.
The nurse is instructed to perform preoperative preparation for the management of a client with malignant tumors. Which of the ff is the most important factor of the nursing management plan?
- A. Insertion of an ostomy pouch
- B. Assessing the symptoms of peritonitis
- C. Maintaining the integrity of the urinary
- D. Insertion of a nasogastric tube diversion procedure
Correct Answer: B
Rationale: Peritonitis is a serious and potentially life-threatening condition that can occur as a complication of malignant tumors. It is characterized by inflammation of the lining of the abdomen and can result in severe abdominal pain, tenderness, fever, and other symptoms. Prompt assessment of peritonitis symptoms is crucial for early detection and intervention to prevent further complications and improve patient outcomes. Assessing for peritonitis symptoms should be the priority in the nursing management plan to ensure timely and appropriate care for the client with malignant tumors.
The age by which the child can make a tower of 9 cubes and imitates circular stroke is
- A. 24 months
- B. 30 months
- C. 36 months
- D. 42 months
Correct Answer: C
Rationale: This milestone is typically achieved around 36 months.
When assessing a female adolescent for scoliosis, what should the nurse ask the client to do?
- A. Bend forward at the waist with arms hanging freely.
- B. Lie flat on the floor and extend her legs straight from the trunk.
- C. Sit in a chair while lifting her feet and legs to a right angle with the trunk.
- D. Stand against a wall while pressing the length of her back against the wall.
Correct Answer: A
Rationale: When assessing a female adolescent for scoliosis, the nurse should ask the client to bend forward at the waist with arms hanging freely. This Adams forward bend test allows the nurse to evaluate the spine for any asymmetry, curvature, or rib hump that may indicate scoliosis. By observing the alignment of the spine while the client is in a forward bent position, the nurse can gather important information to determine if further evaluation or referral to a healthcare provider is necessary.