Nokea
Which question is most important for the nurse to ask the client with a cystocele who is scheduled to have a pessary inserted?
- A. Do you know if you are allergic to latex?'
- B. When did you start having incontinence?'
- C. When was your last bowel movement?'
- D. Are you experiencing any pelvic pressure?'
Correct Answer: A
Rationale: Latex allergies are critical to assess before pessary insertion, as many pessaries are latex-based, risking anaphylaxis. Incontinence history, bowel movements, and pelvic pressure are relevant but secondary to safety.
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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.
When the client asks where the laparoscope will be inserted, the nurse correctly identifies which structure?
- A. Abdomen
- B. Vagina
- C. Uterine cervix
- D. Uterine fundus
Correct Answer: A
Rationale: For endometriosis, a laparoscope is inserted through a small abdominal incision to visualize and remove ectopic tissue.
Which information should the nurse include in the discharge teaching for the client recovering from an abdominal hysterectomy?
- A. The client should report any vaginal bleeding or cramping to the surgeon.
- B. The client should start a vigorous exercise routine to restore her muscle tone.
- C. The client should continue sitting in the bedside chair at least six (6) hours daily.
- D. The client should soak in a warm tub bath each night for one (1) hour.
Correct Answer: A
Rationale: Reporting vaginal bleeding or cramping is critical, as these may indicate complications like hemorrhage or infection. Vigorous exercise is contraindicated, prolonged sitting is unnecessary, and tub baths risk infection.
The client has a diagnosis of rule-out Paget’s disease. Which test provides a definitive diagnosis of the disease?
- A. A breast biopsy.
- B. A diagnostic mammogram.
- C. Ultrasound of the breast.
- D. Magnetic resonance imaging.
Correct Answer: A
Rationale: Breast biopsy provides a definitive diagnosis for Paget’s disease by confirming malignant cells in the nipple/areola. Mammogram, ultrasound, and MRI are supportive but not confirmatory.
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.