Nokea
Which question is most important for the nurse to ask next?
- A. Have you ever had any menstrual periods?
- B. Do you have any pubic hair growth?
- C. Have you ever been sexually attracted to males?
- D. Are there any siblings with a similar problem?
Correct Answer: A
Rationale: Determining if the client has ever menstruated is critical to differentiate between primary amenorrhea (never menstruated) and secondary amenorrhea (cessation of periods), guiding further assessment.
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The nurse is assessing the client diagnosed with a rectocele. Which signs and symptoms should the nurse expect? Select all that apply.
- A. Rectal pressure.
- B. Flatus.
- C. Fecal incontinence.
- D. Constipation.
- E. Urinary frequency.
Correct Answer: A,B,C,D
Rationale: Rectocele causes rectal pressure, flatus, fecal incontinence, and constipation due to posterior vaginal wall protrusion. Urinary frequency is more associated with cystocele.
The 30-year-old male client diagnosed with germinal cell carcinoma of the testes asks the nurse, 'What chance do I have? Should I end it all now?' Which response by the nurse indicates an understanding of the disease process?
- A. God does not want you to give up hope and end it all now.'
- B. There is a good chance for survival with standard treatment options.'
- C. There may be little hope, but ending it all is not the answer.'
- D. You have a 50/50 chance of living for at least 5 years.'
Correct Answer: B
Rationale: Germinal cell carcinoma has a high cure rate with treatment (e.g., orchiectomy, chemotherapy), offering good survival chances. Religious references, pessimism, or vague statistics are less appropriate.
Although it has not been conclusively proven, the nurse explains that some women with fibrocystic disease get relief from their symptoms by eliminating which substance from their diet?
- A. The blood
- B. Caffeine
- C. Saturated fat
- D. Refined sugar
Correct Answer: B
Rationale: Caffeine is thought to exacerbate fibrocystic breast symptoms in some women by stimulating breast tissue, and reducing intake may provide symptom relief, though evidence is not definitive.
Which health practice is most appropriate for the nurse to teach this client?
- A. Take showers rather than tub baths if possible.
- B. Wipe away from the vagina after a bowel movement.
- C. The client's sexual experience with members of both sexes
- D. Avoid having sexual intercourse more than once a week.
Correct Answer: B
Rationale: Wiping away from the vagina prevents fecal bacteria from entering the vaginal area, reducing the risk of infections like candidiasis.
To accurately determine the dosage of antineoplastic drugs, which information is essential to obtain from the client's chart?
- A. Urine output for the past 24 hours
- B. Body weight and height
- C. Date of surgery
- D. Drug allergies
Correct Answer: B
Rationale: Body weight and height are used to calculate body surface area, which determines accurate dosing of antineoplastic drugs.