EXAM #2

A transgender client is taking transdermal estrogen. What assessment finding does the nurse report immediately to the primary health care provider? a. Breast tenderness b. Headaches C. Red, swollen calf d. Swollen ankles

ANS : C A red, swollen calf could be a sign of a deep-vein thrombosis, a known adverse effect of estrogen. The nurse reports this finding immediately. The other signs and symptoms are also side effects of estrogen, but do not need to be reported as a priority.

A client has just returned from a right radical mastectomy. Which action by the assistive personnel (AP) would require the nurse consider to intervene? a. Checking the amount of urine in the catheter collection bag b. Elevating the right arm on a pillow c. Taking the blood pressure on the right arm d. Encouraging the client to squeeze a rolled washcloth

ANS : C Health care professionals need to avoid the arm on the side of the surgery for blood pressure measurement, injections, or blood draws . Since lymph nodes are removed, lymph drainage would be compromised. The pressure from the blood pressure cuff could promote swelling. Infection could occur with injections and blood draws Checking urine output, elevation of the affected arm on a pillow, and encouraging beginning exercises are all safe postoperative interventions.

A nurse has taught a female client about the modifiable risk factors for breast cancer. Which statement made by the client indicates that more teaching is needed? a. "I am fortunate that I breast-fed each of my three children for 12 months." b. "It looks as though I need to start working out at the gym more often." c. "I am glad that we can still have wine with every evening meal." d. "When I have menopausal symptoms, I must avoid hormone replacement therapy."

ANS : C Modifiable risk factors can help prevent breast cancer. The client should lessen alcohol intake and not have wine 7 days a week. Breast-feeding, regular exercise, maintaining a normal weight, and avoiding hormone replacement are also strategies for breast cancer prevention

The nurse is providing preoperative education to a client prior to having an orchiectomy for testicular cancer . What statement by the client indicates the need to review the information ? a . "I can still function sexually without one of my testes." b . "I will investigate sperm banking before the operation." c . "There should be no effect on my ability to reproduce." d . "Testicular self - exam will be important on the remaining testis."

ANS : C Oligospermia and azoospermia are common in clients with testicular function and can affect reproduction . The statement that there will be no effect on reproduction requires the nurse to review the information with the client . Sperm banking is an option prior to treatment to store sperm for future use . Normal sexual function is possible with one testis . Self - examination of the remaining testis is important for early detection of another tumor .

A client is starting hormonal therapy with tamoxifen to lower the risk for breast cancer . What information needs to be explained by the nurse regarding the action of this drug? a. It blocks the release of luteinizing hormone. b. It interferes with cancer cell division. c. It selectively blocks estrogen in the breast. d. It inhibits DNA synthesis in rapidly dividing cells.

ANS : C Tamoxifen reduces the estrogen available to breast tumors to stop or prevent growth. This drug does not block the release of luteinizing hormone to prevent the ovaries from producing estrogen; leuprolide does this. Chemotherapy agents interfere with cancer cell division. Newer research supports treatment with tamoxifen for 10 years to prevent recurrence.

A nurse is assessing a client who presents with a scaly rash over the palms and soles of the feet and the feeling of muscle aches and malaise. Which action by the nurse is most appropriate? a. Reassure the client that these lesions are not infectious b. Assess the client for hearing loss and generalized weakness. c. Don gloves and further assess the client's lesions. d. Take a history regarding any cardiovascular symptoms.

ANS : C The client is displaying symptoms similar to secondary syphilis , with flulike symptoms and rash due to the spirochetes circulating throughout the bloodstream . Therefore , the nurse needs to further assess the client's lesions with gloves since the client is highly contagious at this stage . Tertiary syphilis may display in the form of cardiovascular or central nervous system symptoms . Neurosyphilis can appear at any time , in any state , and can include hearing loss .

A woman is admitted to the hospital for antibiotic therapy for pelvic inflammatory disease. She is in pain, with a rating of 7 on a scale of 0-10. What comfort measure can the nurse delegate to assistive personnel (AP)? a. Administer acetaminophen with codeine. b. Apply an ice pack to the lower abdomen. c. Position the client in a semi-Fowler position. d. Teach the client to increase intake of fluids.

ANS : C The client with pelvic inflammatory disease usually experiences lower abdominal tenderness. The AP can position the client. Only the nurse can administer medications and perform teaching . A heating pad, not an ice pack, is used for comfort.

The nurse is examining a woman's breast and notes multiple small mobile lumps. Which question would be most appropriate for the nurse to ask? a. "When was your last mammogram at the clinic?" b. "How many cans of caffeinated soda do you drink in a day?" c. "Do the small lumps seem to change with your menstrual period?" d. "Do you have a first-degree relative who has breast cancer?"

ANS : C The most appropriate question would be one that relates to benign lesions that usually change in response to hormonal changes within a menstrual cycle. Reduction of caffeine in the diet has been shown to give relief in fibrocystic breast changes, but research has not found that it has a significant impact. Questions related to the client's last mammogram or breast cancer history are not related to the nurse's assessment.

A nurse is reviewing the chart of a new client in the family medicine clinic and notes that the client is identified as "George Smith." The nurse enters the room and finds a woman in a skirt. What action by the nurse is best? a. Apologize and declare confusion about the client. b. Ask Mrs. Smith where her husband is right now. C. Ask the client about preferred forms of address. d. Explain that the chart must contain an error.

ANS : C The nurse may encounter transgender clients whose outward appearance does not match their demographic data . In this case , the nurse should greet the client and ask the client to explain his or her preferred forms of address . Lengthy apologies can often create embarrassment . The nurse should not assume that the client is not present in the room . The chart may or may not contain errors , but that is not related to determining how the client prefers to be addressed .

A female client returned to the clinic with a yellow vaginal discharge after being treated for Chlamydia infection 3 weeks ago. Which statement by the client alerts the nurse that there may be a recurrence of the infection? a. "I did practice abstinence while taking the medication." b. "I took doxycycline two times a day for a week." c. "I never told my boyfriend about the infection." d. "I did drink wine when taking the medication for Chlamydia."

ANS : C There is a good possibility that the boyfriend reinfected the client after the medication regimen was finished . Both the client and the boyfriend need to be treated . The other statements were in compliance with the recommendations of abstinence and the usual medication regimen with doxycycline . Wine should not interfere with the treatment .

A client presents to the emergency department reporting vomiting, severe lower abdominal pain, and a tender mass above one testis. What action by the nurse is most important? a. Have the client rate pain using the 0-10 scale. b. Prepare to administer an IV opioid analgesic. c. Determine when he last ate or drank anything. d. Assess risk factors for testicular cancer.

ANS : C This client has signs and symptoms of testicular torsion , which is a surgical emergency . For client safety the nurse assesses last oral intake . Rating the pain is an important intervention too but is not related to safety . The client cannot have opioids prior to signing a surgical consent . The client does not have signs and symptoms of testicular cancer.

A client has been treated for syphilis with IM penicillin. The next day the client calls the clinic to report fever, chills, achy muscles, and a worsening rash. What statement by the nurse is most appropriate? a. "You must be allergic to penicillin; over the counter antihistamines will help." b. "Please go to the nearest emergency department if you develop shortness of breath." c. "You can take acetaminophen or ibuprofen for the pain and achiness." d. "I think you should come in to the clinic either today or tomorrow and be checked."

ANS : C This client has signs of a Jarisch-Herxheimer reaction which is caused when the organisms ' cell walls are disrupted and cellular contents are released rapidly. It is usually self-limiting and benign. Antipyretics and mild analgesics treat the symptoms . The client does not need to monitor for shortness of breath, come in to the clinic, or get antihistamines for an allergic reaction.

The nurse is assessing the reproductive history of a 68-year-old postmenopausal woman. Which finding is cause for immediate action by the nurse? A. Vaginal dryness b. No Papanicolaou test for 3 years c. Bleeding from the vagina d. Leakage of urine

ANS : C Vaginal bleeding is not normal for the postmenopausal woman . Vaginal dryness and leakage of urine are common findings in adults of this age range. Pap tests may not be needed for women over 65 who have had regular cervical cancer testing with normal results.

A client returned from a transurethral resection of the prostate 8 hours ago with a continuous bladder irrigation. The client reports headache and dizziness. What action by the nurse is most appropriate? a. Consider starting a blood transfusion. b. Slow the bladder irrigation down. c. Report the findings to the surgeon immediately. d. Take the vital signs every 15 minutes.

ANS : C Headache, dizziness and shortness of breath are symptoms of possible TURP syndrome in which the irrigation fluid is absorbed, putting strain on the client's heart. The nurse notifies the primary health care provider immediately as the client may need intensive care monitoring. There is no data indicating the client needs a blood transfusion, plus that would add even more fluid in the system. The irrigant may need to be slowed but that is not the first action the nurse would take. Vital signs do need to be taken frequently in this situation, but the nurse notifies the primary health care provider first.

Which finding in a female client by the nurse would receive the highest priority for further diagnostics? a. Tender moveable masses throughout the breast tissue b. Nipple discharge without a palpable mass c. Nontender fixed mass in the upper outer quadrant of the breast d. Small, painful mass under warm reddened skin and nipple discharge

ANS : C Malignant lesions are fixed, hard and irregularly shaped and this lesion would be the priority for further diagnostic study. The other lesions are benign breast disorders. The client with nipple discharge but no palpable mass most likely has intraductal papilloma. The client who has nipple discharge but also has a mass under warm, red, edematous skin most likely has ductal ectasia.

A transgender client taking spironolactone is in the internal medicine clinic reporting heart palpitations . What action by the nurse takes priority? a. Draw blood to test serum potassium . b. Have the client lie down and rest . C. Obtain a STAT electrocardiogram (ECG). d. Take a set of vital signs.

ANS : C Spironolactone is a potassium-sparing diuretic, and hyperkalemia can cause cardiac dysrhythmias. The nurse's priority is to obtain an ECG, and then to facilitate a serum potassium level being drawn. Having the client lie down and obtaining vital signs are also important care measures, but are not the most important at this time.

What should the nurse evaluate before administering the Denver Developmental Screening Test II ( DDST II ) ? Select all that apply . a . The childs height and weight b . The parents ability to comprehend the results c . The childs mood d . The parent - child interaction e . The childs chronologic age

ANS : C , E

A younger woman from an unfamiliar culture is at high risk for breast cancer and is considering a prophylactic mastectomy and oophorectomy. What action by the nurse is most appropriate? a. Discourage this surgery since the woman is still of childbearing age b. Reassure the client that reconstructive surgery is as easy as breast augmentation. c. Inform the client that this surgery removes all mammary tissue and cancer risk. d. Offer to include support people, such as the male partner, in the decision making.

ANS : D

The mother of an 18-year-old girl asks the nurse which screening her daughter would receive now based on evidence-based recommendations . Which suggestion by the nurse is best? a. Papanicolaou test b. Human papilloma virus (HPV) test c. Mammogram d. No screenings at this time

ANS : D

Which immunizations should be used with caution in children with an allergy to eggs ? a HepB b . DTaP C. Hib d . MMR

ANS : D

During dressing changes , the nurse assesses a client who had breast reconstruction. Which finding would cause the nurse to take immediate action? a. Slightly reddened incisional area b. Blood pressure of 128/75 mm Hg c. Temperature of 99°F (37.2°C) d. Dusky color of the breast flap

ANS : D A dusky color of the breast flap could indicate poor tissue perfusion. The nurse would notify the primary health care provider to preserve the tissue. It is normal to have a slightly reddened incision as the skin heals. The blood pressure is within normal limits and the temperature is slightly elevated but would be monitored

A client with pelvic inflammatory disease is seen by the nurse 72 hours after starting oral antibiotics. Which finding leads the nurse to take immediate action? a. Feelings of anger that her partner infected her b. Loose stools over the last 2 days c. Anorexia and nausea d. Chills and a temperature of 101 F (38.3°C)

ANS : D Chills and fever could indicate a persistent infection and the immediate need to alter the dose or type of antibiotic. Anger is a normal reaction to a sexually transmitted infection and the pain of pelvic inflammatory disease. Gastrointestinal symptoms are common side effects of antibiotics but not an immediate cause for intervention.

A 30-year-old male client is asking the nurse about the vaccine for human papilloma virus (HPV). Which statement by the nurse is accurate? a. "Gardasil protects against all HPV strains." b. "You are too old to receive the vaccine." c. "Only females can receive the vaccine." d."You will only need 1 dose of the vaccine."

ANS : D Gardasil is used to provide immunity for HPV types 6, 11 , 16, and 18 and Gardasil 9 protects against 5 more strains. The vaccine is recommended for people aged 9 to 26 years of age, but Gardasil 9 can be given up to age 45. Both males and females can get the vaccine. Depending on the timing and type of vaccine , either 2 to 3 doses are require.

The nurse is developing a teaching plan for a client who is scheduled for her first Papanicolaou test. What instruction by the nurse is the most accurate? a. "The timing of the Pap smear does not matter." b. "Sexual intercourse will not interfere with the results." c. "Results can be interpreted immediately in the office." d. "Results are best if you do not douche 24 hours before the test."

ANS : D In order to prevent false interpretation , the client must not douche , use vaginal medications or deodorants , or have sexual intercourse for at least 24 hours before the Pap smear . Timing is important , with the test scheduled between the client's menstrual periods so that the menstrual flow does not interfere with laboratory analysis . The specimens are placed on a glass slide and sent to the laboratory for examination and cannot be interpreted immediately .

While evaluating a client for treatment of gonorrhea, which question is the most important for to ask? a. "Do you have a history of sexually transmitted infection?" b. "When was your last sexual encounter?" c. "When did your symptoms begin?" d. "Can you remember your partners and contact them to get treated?"

ANS : D Sexual partners, as well as the client, should be tested and treated for gonorrhea. Asking about sexually transmitted infection history, last sexual encounter, and onset of symptoms would be helpful with the history taking, but the priority is treating the client's sexual partners to limit the spread of the infection.

The nurse is caring for a postoperative client following an anterior colporrhaphy . What action can be delegated to the assistive personnel ( AP ) ? a. Reviewing the hematocrit and hemoglobin results b. Teaching the client to avoid lifting her 4 - year - old grandson c. Assessing the level of pain and any drainage d. Drawing a shallow hot bath for comfort measures

ANS : D The AP is able to provide comfort through a bath . The registered nurse would review any laboratory results , complete any teaching , and assess pain and discharge .

A client is scheduled for a laparoscopy to remove endometriosis tissue. Which response by the client alerts the nurse of the need for further teaching? a. "The surgeon told me that carbon dioxide would be infused into my pelvic cavity." b. "There will be one or more small incisions in order to visualize all of the organs." c . "There will be some shoulder pain after the procedure that may last 48 hours. " d. "I can return to jogging my 3-mile (5 km) routine in a few days."

ANS : D The client is taught that she should not participate in strenuous activity for a week after the procedure. Carbon dioxide is infused into the pelvic cavity to visualize the organs. There are only one or more small incisions with this procedure. The referred shoulder pain that will occur only lasts 48 hours.

A client is diagnosed with benign prostatic hyperplasia and seems sad and irritable . After assessing the client's behavior , which statement by the nurse would be the most appropriate ? A. "The urine incontinence should not prevent you from socializing B. "You seem depressed and should seek more pleasant things to do." C. "It is common for men at your age to have changes in mood." D. "Nocturia could cause interruption of your sleep and cause changes in mood"

ANS : D Frequent visits to the bathroom during the night could cause sleep interruptions and affect the client's mood and mental status . Telling the client his symptoms should not lead to less socialization is patronizing . Instructing the client to seek more pleasant things to do also is patronizing . Neither statement has any information the client could find useful . The statement about age has no validity and again does not offer useful information .

A client has undergone a vaginal hysterectomy with a bilateral salpingo - oophorectomy . She is concerned about a loss of libido . What intervention by the nurse would be best ? a. Suggest increasing vitamins and supplements daily. b. Discuss the value of a balanced diet and exercise. c. Reinforce that weight gain may be inevitable. d. Teach that estrogen cream inserted vaginally may help.

ANS : D Use of vaginal estrogen cream and gentle dilation can help with vaginal changes and loss of libido . Weight gain and masculinization are misperceptions after a vaginal hysterectomy . Vitamins , supplements , a balanced diet , and exercise are helpful for healthy living , but are not necessarily going to increase libido .

You are preparing immunizations for a 12 - month - old child who is immunocompromised . Which immunizations cannot be given ? Select all that apply. a . DTaP b . HepA C. IPV d . Varicella e . MMR

ANS : D , E

1When counseling parents and children about the importance of increased physical activity , the nurse can emphasize a . Anaerobic exercise should comprise a major component of the childs daily exercise . b . All children should be physically active for at least 2 hours per day . C. It is not necessary to participate in physical education classes at school if a student is taking part in other activities . d . Making exercise fun and a habitual activity .

ANS : D.

Breastfeeding is the ideal method for providing nutrition to the human infant and is recommended by the American Heart Association , the American Academy of Pediatrics , and the World Health Organization . Infants should be exclusively breastfed for a minimum of 4 months and preferably 6 months . Is this statement true or false ?

ANS : T

A type of play that allows children to act out roles and experiences that may have happened to them , that they fear may happen , or that they have observed in others is known as ____ play .

ANS : dramatic

The nurse is conducting a history on a male client to determine the severity of symptoms associated with prostate enlargement . Which finding is cause for prompt action by the nurse ? a . Hematuria b . Urinary hesitancy c . Postvoid dribbling d . Weak urinary stream

ANS A Hematuria especially at the start or end of the urine stream , could indicate infection due to possible urine retention and would cause the nurse to act promptly . Common symptoms of benign prostatic hyperplasia are urinary hesitancy , postvoid dribbling , and a weak urinary stream due to the enlarged prostate causing bladder outlet obstruction .

Which child is most likely to be frightened by hospitalization ? a . A 4 - month - old infant admitted with a diagnosis of bronchiolitis b . A 2 - year - old toddler admitted for cystic fibrosis C. A 9 - year - old child hospitalized with a fractured femur d . A 15 - year - old adolescent admitted for abdominal pain

ANS B

The nurse has provided postvasectomy discharge instructions to the client . What statement by the client demonstrates good understanding ? a. "We can have unprotected intercourse as soon as I have healed." b. "An ice pack to my scrotum will help with the swelling." c. "I need to report signs of infection, swelling, or bruising right away." d. "The stitches can be removed here in the office in 7 to 10 days."

ANS B After vasectomy , clients are instructed to use birth control until the 3 - month semen analysis shows that the procedure has worked , to use an ice pack intermittently for 24 to 48 hours , that swelling and bruising are normal , and the bandage can be removed in 48 hours . There are no sutures to be removed .

A new nurse care for several client after radical prostatectomies for prostate cancer . What action by the nurse indicates a need to review care measures for this type of client ? a . Delegates emptying and recording contents of the drainage devices b . Administers a suppository to the client who reports constipation . c . Removes the sequential compression stockings on ambulatory clients . d . Discusses long - term complications such as erectile dysfunction .

ANS B After a radical prostatectomy , the nurse would not provide a rectal suppository for constipation . All rectal treatments are contraindicated . The nurse would delegate emptying and recording drainage , remove the sequential pressure devices when clients begin ambulating , and discuss long - term complications of the operation .

A nurse is providing education to a new 55 - year - old African - American client about screening for prostate cancer . What action by the nurse is most appropriate ? A. Inform the client that recommendations vary , so screening is a personal choice . B. Let the client know that as an African American , he should be screened annually C. Teach the client that he is in a high risk group and should discuss screening . D. Give the client written information that discourages screening until age 70 .

ANS: C Clients in certain high risk groups should discuss screening for prostate cancer with their primary health care providers at age 45. High risk groups include African Americans and men with a first - degree relative who was diagnosed with prostate cancer before the age of 65. This new client will be encouraged to discuss screening even though he is past the age of initial discussion . Recommendations do vary somewhat , but he is in a recognized high risk group The nurse would not say that he " should " be screened annually . Screening is not recommended for men over the age of 70 .

A 67-year-old male client had serum laboratory tests performed during his annual examination. The nurse reviews his results, as follows: testosterone: 680 ng/dL(23.6 nmol/L); prostate-specific antigen: 10 ng/mL ( 10 mcg/L); prolactin: 5 ng/mL (217.4 pmol) . What action by the nurse is best? a. Assess for possible galactorrhea with breast discharge. b. Note the possibility of a testicular tumor. c. Communicate that results were normal. d. Prepare the client for further diagnostic testing.

D The prostate-specific antigen is increased from the normal of 0 to 2.5, which could indicate benign prostatic hyperplasia or prostate cancer. Further testing would have to be done. The other values are within the normal range for males.

The environment , both physical and psychosocial , is a significant determinate of growth and development outcomes before and after birth . Nurses can assist parents in preventing environmental injury for their 2 - year old toddler by teaching them to avoid the most common sources of exposure . This anticipatory guidance includes teaching related to a . Avoiding sun exposure , secondhand smoke , and lead B . Socioeconomic status , primarily poverty C. Maternal smoking and alcohol intake during pregnancy d . The passing of environmental toxins through breast milk

ANS : A

The theorist who viewed developmental progression as a lifelong series of conflicts that need resolution is a.Erikson b . Freud C. Kohlberg d Piaget

ANS : A A Erik Erikson viewed development as a series of conflicts affected by social and cultural factors . Each conflict must be resolved for the child to progress emotionally , with unsuccessful resolution leaving the child emotionally disabled . B Sigmund Freud proposed a psychosexual theory of development . He proposed that certain parts of the body assume psychological significance as foci of sexual energy . The foci shift as the individual moves through the different stages ( oral , anal , phallic , latency , and genital ) of development . с Lawrence Kohlberg described moral development as having three levels ( preconventional , conventional , and postconventional ) . His theory closely parallels Piagets . D Jean Piagets cognitive theory interprets how children learn and think and how this thinking progresses and differs from adult thinking . Stages of his theory include sensorimotor , preoperations , concrete operations , and formal operations .

The nurse is teaching a client with benign prostatic hyperplasia (BPH). What statement indicates the client needs further information? A. "There should be no problem with drinking wine with dinner each night." B. "I am so glad that I weaned myself off of coffee about a year ago." C. "I need to inform my allergist that I cannot take my normal antihistamine." D. "My routine of drinking a quart (liter) of water first thing in the morning needs to change."

ANS : A Caffeine and alcohol have diuretic effects and so the nurse would teach about avoiding or limiting their intake. The statement about drinking wine indicates a need for further instruction. Antihistamines can cause urinary retention . Clients are taught to avoid drinking large quantities of fluid at one time.

A 24 year-old female has been diagnosed with genital warts. Which action by the nurse is best? a. Encourage the client to complete STI screening. b. Recommend an over-the-counter wart treatment for genital tissue. c. Report the case to the Centers for Infection Control and Prevention (CDC). d. Discuss popular options for contraception.

ANS : A Clients with HPV should be fully screened for other STIS since co-infection is common. Over the counter treatments should not be applied to genital tissue. HPV is not reportable. Contraception is not related.

A client is placed on a medical regimen of doxorubicin (Adriamycin), cyclophosphamide, and fluorouracil for breast cancer. Which side effect seen in the client would the nurse report to the primary health care provider immediately? a. Shortness of breath b. Nausea and vomiting c. Hair loss . d. Mucositis

ANS : A Doxorubicin can cause cardiotoxicity with symptoms of extreme fatigue, shortness of breath, chronic cough, and edema. These need to be reported as soon as possible to the primary health care provider. Nausea, vomiting, hair loss, and mucositis are common problems associated with chemotherapy regimens

A client is having a hysterosalpingogram. What action by the nurse is most important? a. Assist the client in sitting up after the procedure. b. Provide the client with a pad to avoid dye stains on the clothes. c. Teach her to take all antibiotics prescribed until finished. d. Inform the client that the procedure may cause shoulder pain.

ANS : A During the procedure, the client may experience light- headedness, so the nurse would assist her with sitting up afterwards for safety. The nurse does provide a pad to prevent any staining from the dye and does inform the client of the possibility of shoulder pain, but an action to prevent injury is more important. Antibiotics are not prescribed afterward.

A client has returned from the postanesthesia care unit after a vaginoplasty. What comfort measure does the nurse provide for this client? a. Apply ice to the perineum. b. Elevate the legs on pillows. c. Position the client on the left side. d. Raise the head of the bed.

ANS : A Ice is applied to the perineum intermittently to reduce bruising , pain , and discomfort. Elevating the legs on pillows is not recommended after a lengthy procedure in the lithotomy position, which predisposes the client to venous thromboembolism. Positioning the client on the left side and raising the head of the bed are not comfort measures related to this procedure.

A woman diagnosed with breast cancer had these laboratory tests performed at an office visit : Alkaline phosphatase 125 U/L ( 2.2 mckat/L) Total calcium 12 mg/dL (3 mmol/L) Hematocrit 39% (0.39) Hemoglobin 14 g/dL (140 mmol/L) Which test results indicate to the nurse that some further diagnostics are needed? a. Elevated alkaline phosphatase & calcium suggests bone involvement. b. Only alkaline phosphatase is decreased, suggesting liver metastasis. c. Hematocrit & hemoglobin are decreased, indicating anemia. d. The elevated hematocrit & hemoglobin indicate dehydration.

ANS : A The alkaline phosphatase (normal value 30 to 120 U/L [0.5 to 2.0 mckat/L ]) and total calcium (normal value 9 to 10.5 mg/dL[2.25 to 2.63 mmol / L]) levels are both elevated, suggesting bone metastasis. Both the hematocrit and hemoglobin are within normal limits for females.

A client is discharged to home after a modified radical mastectomy with two drainage tubes. Which statement by the client would indicate that further teaching is needed? a. "I am glad that these tubes will fall out at home when I finally shower." b. "I should measure the drainage each day to make sure it is less than an ounce (30 mL)." c. "I should be careful how I lie in bed so that I will not kink the tubing." d. "If there is a foul odor from the drainage, I will contact my primary health care provider."

ANS : A The drainage tubes (such as a Jackson-Pratt drain) lie just under the skin but need to be removed by the health care professional in about 1 to 3 weeks at an office visit. Drainage should be less than 30 mL for three consecutive days. The client should be aware of her positioning to prevent kinking of the tubing. A foul odor from the drainage may indicate an infection; the primary health care would be contacted immediately.

The nurse is teaching an uncircumcised 65-year-old client about self- management of a urinary catheter in preparation for discharge to his home. What statement indicates the client needs more information? a. "I have to wash the outside of the catheter once a day with soap and water. b. "I should take extra time to clean the catheter site by pushing the foreskin back." c. "The drainage bag needs to be changed at least once a week and as needed." d. "I should pour a solution of vinegar and water through the tubing and bag."

ANS : A The first few inches (centimeters) of the catheter must be washed daily starting at the penis and washing outward with soap and water. The other options are correct for self-management of a urinary catheter in the home setting.

A client with multiple sexual partners has been assessed for symptoms of dysuria and green, malodorous vaginal discharge. The nurse administers and injection of ceftriaxone and gives the client a prescription for doxycycline. The client asks why two drugs are needed. What answer by the nurse is best? a. "It is very common to be infected with both gonorrhea and chlamydia." b. "Giving two medications increases the chance of curing the infection." C. "Some people are not affected by the injection and need more medication." d. "This will prevent you from needing a 3-month follow-up test."

ANS : A This client has signs of gonorrhea. Co-infection with gonorrhea and chlamydia is common, so the client being treated for gonorrhea also needs treatment for chlamydia with oral antibiotics. It is fairly accurate to say two medications increases the chance of cure, but does not really explain the situation. Giving the client two medications is not because some people are not affected by the injection nor is it to prevent needing a 3-month follow-up test . Testing for re-infection with chlamydia is recommended by the CDC.

1. Which statement best describes development in infants and children? a. Development, a predictable and orderly process occurs at varying rates within normal limits. b. Development is primarily related to the growth in the number and size of cells. C. Development occurs in a proximodistal direction with fine muscle development occurring first. d. Development is more easily and accurately measured than growth

ANS : A A Development , a continuous and orderly process , provides the basis for increases in the childs function and complexity of behavior . The increases in rate of function and complexity can vary normally within limits for each child . B An increase in the number and size of cells is a definition for growth . с Development proceeds in a proximodistal direction with fine muscle organization occurring as a result of large muscle organization D Development is a more complex process that is affected by many factors ; therefore , it is less easily and accurately measured . Growth is a predictable process with standard measurement methods .

The nurse is teaching a 45-year-old woman about her fibrocystic breast changes. Which statement by the client indicates a lack of understanding? a. "This condition will become malignant over time." b. "I understand that hormone-based drugs have serious adverse effects." c. "One cup of coffee in the morning should be enough for me." d. "This condition makes it more difficult to examine my breasts."

ANS : A Fibrocystic breast changes do not increase a woman's chance of developing breast cancer. Hormone-based drugs can be used in severe cases to suppress the over-secretion of estrogen . Serious adverse effects include thrombotic events and an increased risk for uterine cancer. Limiting caffeine intake may give relief for tender breasts. The fibrocystic changes to the breasts make it more difficult to examine the breasts because of fibrotic changes and lumps.

A nurse receives hand - off report on four postoperative clients who each had total hysterectomies . Which client would the nurse assess first upon initial rounding ? a . Vaginal hysterectomy : two saturated perineal pads in 2 hours b . Abdominal : temperature of 99 ° F ( 37.2 ° C ) , blood pressure of 116/74 mm Hg c . Vaginal : opened incisional edges and moderate bleeding d . Abdominal : urinary catheter output of 150 mL in the last 3 hours

ANS : A Normal vaginal bleeding after a vaginal hysterectomy should be less than one saturated perineal pad in 4 hours . Two saturated pads in such a short time could indicate hemorrhage , which is a priority . The client with the slight temperature elevation needs to be assessed for possible infection , but not as the priority . A vaginal hysterectomy would not result in an incision the nurse could observe separating . The urinary output is normal .

The nurse is educating a client on the prevention of toxic shock syndrome ( TSS ) . Which statement by the client indicates a lack of understanding ? a. "I need to change my tampon every 8 hours during the day." b. "At night , I should use a feminine pad rather than a tampon." c. "If I don't use tampons , I should not get TSS." d. "It is best if I wash my hands before inserting the tampon."

ANS : A Tampons need to be changed every 3 to 6 hours to avoid infection by such organisms as Staphylococcus aureus . All of the other responses are correct : use of feminine pads at night , not using tampons at all , and washing hands before tampon insertion are all strategies to prevent TSS .

A nurse is providing health teaching to a middle-age male-to-female (MtF) client who has undergone gender-reaffirming surgery. What information is most important to this patient? a . "Be sure to have an annual prostate examination . b. "Continue your normal health screenings." c. "Try to avoid being around people who are ill." d. "You should have an annual flu vaccination."

ANS : A The MtF client retains the prostate , so annual screening examinations for prostate cancer remain important . The other statements are good general health teaching ideas for any patient.

The nurse is reviewing information about FtM gender-affirming surgical options with a client. What statement by the client indicates the need for further information? a. "A penile implant is inserted during the phalloplasty." b. "Vaginal atrophy can occur and lead to itching." C. "I will still need cervical cancer screening if I don't have a total hysterectomy." d. "This surgery will have many psychologic benefits for me."

ANS : A The penile implant or prosthesis is not implanted with the original phalloplasty, but months later when the original operation has healed. The other statements are accurate regarding gender-affirming surgery.

A client comes to the clinic with concerns about an enlarged left testicle and heaviness in his lower abdomen. Which diagnostic test would the nurse expect to be ordered? a. Alpha-fetoprotein (AFP) b. Prostate-specific antigen (PSA) C. Serum acid phosphatase (PAP) d. C-reactive protein (CRP)

ANS : A These are symptoms of possible testicular cancer . AFP is a tumor marker that is elevated in testicular cancer. PSA and PAP testing is used in testing for prostate cancer and its metastasis. CRP is diagnostic for inflammatory conditions.

A primary care clinic sees some clients with sexually transmitted infections. Which diseases would the nurse be required to report to the local authority? (Select all that apply.) a. Chlamydia b. Gonorrhea c. Syphilis d. Human immune deficiency virus e. Pelvic inflammatory disease f. Human papilloma virus

ANS : A , B , C , D Chlamydia, gonorrhea, syphilis, human immune deficiency virus (HIV), and acquired immune deficiency syndrome (AIDS) are all reportable to local authorities in every state. Pelvic inflammatory disease and HPV do not need to be reported.

A client has pelvic inflammatory disease (PID). What complications does the nurse monitor the client for? (Select all that apply.) a. Chronic pelvic pain b. Infertility c. Ectopic pregnancy d. Tubo-ovarian abscess e. Peri-hepatitis f. Pancreatitis

ANS : A , B , C , D , E Possible complications of PID include chronic pelvic pain, infertility, ectopic pregnancy tubo-ovarian abscess, peri-hepatitis, inflammation of the liver capsule, and inflammation of the peritoneal surfaces of the anterior right upper quadrant.

The nurse is reviewing possible complications from a phalloplasty. What factors does the nurse include? (Select all that apply.) a. Wound infections b. Urethral complications C. Rectal injury d. Bleeding e. Donor site scarring f. Recurrent urinary tract infections

ANS : A , B , C , D , E Complications from phalloplasty include wound infections , urethral complications , rectal injuries , bleeding , and donor site scarring . Recurrent urinary tract infections are not a typical complication .

A nurse works with many transgender patients. What routine monitoring is important for the nurse to facilitate in this population?(Select all that apply.) a. Lipid profile b. Liver function tests c. Mammograms if breast tissue is present d. Prostate-specific antigen (PSA for natal males) e. Renal profile f. Cervical cancer screening

ANS : A , B , C , D , F Common routine monitoring for this population includes lipid and liver panels , mammograms if any breast tissue is present , and PSA for natal males as the prostate is not removed during a vaginoplasty / penectomy . Cervical cancer screening is needed if the client has not had a total hysterectomy with a BSO . Renal profiles are not required based on treatment options for this population .

A nurse is learning about the health care needs of individuals who identify as LGBTQIA+ and transgender. Which terms are correctly defined? (Select all that apply.) a. Gender dysphoria distress caused by incongruence between natal sex and gender identity. b. Gender identity-a person's inner sense of being a male, a female, or an alternative gender . c. Natal sex the sex one is born with or is assigned to at birth . d. Transgender a person who dresses in the clothing of the opposite sex. e. Trans-woman-a male who identified or lives as a woman.

ANS : A , B , C , E Gender dysphoria is emotional distress caused by the incongruence between natal sex (sex assigned at birth) and gender identity. Gender identity is a person's inner sense of being a male, a female, or an alternative gender Natal sex describes the gender a person is born with or is assigned to at birth. Transgender is an adjective that describes individuals who self-identify as the opposite gender or a gender that does not match their natal sex. A trans-woman is a natal male who identifies and/or lives as a woman .

A client came to the clinic with erectile dysfunction. What are some possible causes of this condition that the nurse could discuss with the client during history taking? (Select all that apply.) a. Recent prostatectomy b. Long-term hypertension C. Diabetes mellitus d. Hour-long exercise sessions e. Consumption of beer each night f. Taking long hot baths

ANS : A , B , C , E Organic erectile dysfunction can be caused by surgical procedures, vascular diseases such as hypertension and its treatment, diabetes mellitus, and alcohol consumption. There is no evidence that exercise or hot baths are related to this problem.

The nurse is teaching a client who is taking an oral antibiotic for treatment of a sexually transmitted infection (STI). Which statements by the client indicate a correct understanding of the treatment? (Select all that apply.) a. "I need to drink at least eight glasses of fluid each day with my antibiotic." b. "I should read the instructions to see if I can take the medication with food." c. "Antacids should not interfere with the effectiveness of the antibiotic." d. "I need to wait 7 days after this injection to engage in intercourse." e. "It should not matter if I skip a couple of doses of the antibiotic."

ANS : A , B , D When a client is being treated with an oral antibiotic for an STI , 8 to 10 glasses of fluid should be routine , medication instructions should be reviewed , and at least a week break should occur between the antibiotic and sexual intercourse to allow for the medication's full effects if the medication was given in a single dose . Use of antacids and missing doses could decrease the effectiveness of the antibiotic .

A nurse wants to reduce the risk potential for transmission of chlamydia and gonorrhea with a client diagnosed with both infections. Which items should be included in the client's teaching plan? (Select all that apply.) a. Expedited partner therapy b. Abstinence until therapy is completed c. Use of intrauterine devices d. Proper use of condoms e. Rescreening for infection f. Use of oral contraception

ANS : A , B , D , E As part of client/partner education , the nurse should explain the expedited partner therapy (practice of treating both sexual partners by providing medication to the client for the partner). The nurse should also emphasize the need for abstinence from sexual intercourse until treatment is finished, proper use of condoms, and rescreening for reinfection 3 to 12 months after treatment. The use of an intrauterine device and oral contraception is not part of the plan.

1. The nurse is assessing a client for reproductive health problems . What assessments are most important? (Select all that apply.) a. Bleeding b. Pain C.Sexual orientation d. Masses e. Discharge

ANS : A , B , D , E Bleeding , pain , masses , and discharge are common health problems that bring a client to a primary health care provider . Sexual orientation is not considered a health problem . Sexual activity would be assessed as part of the client's history .

A client being treated for syphilis visits the office with a possible allergic reaction to benzathine penicillin G. Which abnormal findings would the nurse expect to document? (Select all that apply.) a. Red rash b. Shortness of breath c. Heart irregularity d. Chest tightness e. Anxiety f. Confusion

ANS : A , B , D , E The nurse should keep all clients at the office for at least 30 minutes after the administration of benzathine penicillin G. Allergic signs and symptoms consist of rash, shortness of breath, chest tightness, and anxiety . Heart irregularity and confusion are not seen as an allergic manifestation.

The nurse is taking a history of a 68-year-old woman. What assessment findings would indicate a high risk for the development of breast cancer? (Select all that apply) a. Age greater than 65 years b. Increased breast density c. Osteoporosis d. Multiparity e. Genetic factors f. Early menarche

ANS : A , B , E , F

After a breast examination, the nurse is documenting assessment findings that indicate possible breast cancer. Which abnormal findings need to be included as part of the client's electronic medical record? (Select all that apply.) a. Peau d'orange b. Dense breast tissue c. Nipple retraction d. Mobile mass at 2 o'clock e. Nontender axillary nodes f. Skin ulceration

ANS : A , C , D , F In the documentation of a breast mass, skin changes such as dimpling (peau d'orange), nipple retraction, and whether the mass is fixed or movable are charted. The location of the mass should be stated by the "face of a clock. "Skin ulceration is also a common sign. Dense breast tissue and nontender axillary nodes are not abnormal assessment findings that may indicate breast cancer.

A woman is interested in alternative and complementary treatments for the nausea and vomiting caused by the side effects of chemotherapy for breast cancer. Which therapies wound the nurse suggest? (Select all that apply.) A. Acupuncture b. Chiropractic c. Journaling d. Aromatherapy e. Shiatsu f. Black cohosh

ANS : A , D , E Alternative and complementary measures are chosen by many women . For nausea and vomiting , the best choices would be acupuncture , aromatherapy , and shiatsu . Chiropractic treatments would help pain . Journaling would be beneficial for fear and anxiety . Black cohosh is frequently used for hot flashes .

The nurse is formulating a teaching plan according to evidence based breast cancer screening guidelines for a 50-year-old woman with low risk factor . Which diagnostic methods would be included in the plan? (Select all that apply.) a. Annual mammogram b. Magnetic resonance imaging (MRI) c. Breast ultrasound d. Breast self-awareness . e. Clinical breast examination f. Self-breast examination

ANS : A , D , E Guidelines from the American Cancer Society include annual mammograms for low risk women starting at the age of 45 and continuing through the age of 54. At 55 , women can continue annual mammography or change to every 2 years . MRI and ultrasound are done for abnormal findings or for high risk women . Breast self - awareness is important so women can detect changes early . Current data shows that SBE is not a valuable screening tool . Asymptomatic women 40 and older should have а a clinical breast exam annually .

A client is interested in learning about the risk factors for prostate cancer. Which factors does the nurse include in the teaching? (Select all that apply.) a. First-degree relative with prostate cancer b. Smoking c. Obesity d. Advanced age e. Eating too much red meat f. Race

ANS : A , D , E , F Risk factors for prostate cancer include having a first degree relative with the disease, advanced age, and African-American race. Smoking, obesity, and eating too much red meat are not considered risk factors. Research is exploring the relationship with diet.

A client has a positive HSV-2 test but is asymptomatic. What action by the nurse is best? a. Encourage the client to have frequent STI screening . b. Teach the client ways to prevent getting STI. c. Provide the same education as if the client were symptomatic. d. Inform the client that partner notification is unnecessary.

ANS : B

A client is preparing for MtF gender-affirming surgery. The client is worried about the voice not sounding feminine enough. What action by the nurse is best? a. Ask if the client has considered vocal cord surgery to change the voice. b. Refer the client for vocal therapy with a speech-language pathologist. C. Teach the client that there will be no effect on the patient's voice . d. Tell the client that the use of hormones will eventually change the voice.

ANS : B

A preschool aged child will be receiving immunizations . Which statement identifies an appropriate level of language development for a 4 - year - old child ? a . The child has a vocabulary of 300 words and uses simple sentences . b . The child uses correct grammar in sentences . c . The child is able to pronounce consonants clearly . d . The child uses language to express abstract thought .

ANS : B

The nurse is reviewing discharge instructions with a client who has just experienced an endometrial biopsy. Which finding would be reported to the primary health care provider immediately? a. Mild cramping b. Slight chills and fever c. Spotting of blood d. Fatigue after anesthesia

ANS : B

Which developmental assessment instrument is appropriate to assess a 5 - year - old child ? a . Brazelton Behavioral Scale b Denver Developmental Screening Test II ( DDST - II ) C. Dubowitz Scale d . New Ballard Scale

ANS : B

Which expected outcome is developmentally appropriate for a hospitalized 4 - year - old child ? a . The child will be dressed and fed by the parents . b . The child will independently ask for play materials or other personal needs . C. The child will be able to verbalize an understanding of the reason for the hospitalization . d . The child will have a parent stay in the room at all times .

ANS : B

Which is the preferred site for administration of the Hib vaccine to an infant ? A. Deltoid b . Anterolateral thigh C. Upper , outer aspect of the arm d . Dorsal gluteal region

ANS : B

A client is concerned about the risk of lymphedema after a mastectomy. Which response by the nurse is best? a. "You do not need to worry about lymphedema since you did not have radiation therapy." B. "Be careful not to injure that arm or get any infection in that arm." c. "Numbness, tingling, and swelling are common sensations after a mastectomy." d. "The risk for lymphedema is a real threat and can be very self limiting."

ANS : B Injury and infection are risk factors for lymphedema; therefore, the client needs to be cautious with activities using the affected arm. Radiation therapy is just one of the factors that could cause lymphedema. Other risk factors include obesity and presence of axillary disease. The symptoms of lymphedema are heaviness , aching, fatigue, numbness, tingling, and swelling, and are not common after the surgery. Women with lymphedema live fulfilling lives.

A 72year-old woman is being assessed by the nurse for an annual physical. Which finding is of concern to the nurse? a. Thinning of pubic hair b. Increased size of the uterus C. Decreased size of the clitoris d. Loss of tone of the pelvic ligaments

ANS : B An increased size of the uterus is an abnormal finding and would be assessed further . Normal changes in the reproductive system related to aging include the graying and thinning of pubic hair , decreased size of the labia majora and clitoris , and loss of tone and elasticity of the pelvic ligaments and connective tissue . The uterus would normally be decreased , not increased , in size due to changes in hormonal levels and atrophy .

A male client is diagnosed with primary syphilis. Which question by the nurse is a priority at this time? a. "Have you been using latex condoms b. "Are you allergic to penicillin?" c. "When was your last sexual encounter?" d. "Do you have a history of sexually transmitted infections?"

ANS : B Benzathine penicillin G is the evidence - based treatment for primary , secondary , and early latent syphilis . The client needs to be assessed for allergies before treatment . The other questions would be helpful in the client's history of sexually transmitted infections but not as important as knowing whether the client is allergic to penicillin .

A client has returned from a transurethral resection of the prostate with a continuous bladder irrigation . Five hours after the operation , the nurse notes the drainage is bright red with clots . What action should the nurse take first ? a . Review the most recent hemoglobin and hematocrit . b . Take vital signs and begin immediate irrigation with sterile water c . Notify the primary health care provider immediately . d . Remind the client not to pull on the catheter

ANS : B Bright red urinary drainage with clots may indicate arterial bleeding . The nurse would notify the primary health care provider immediately and begin irritating the catheter with sterile normal saline ( not sterile water ) . The nurse can delegate the vital signs . The nurse would review hemoglobin and hematocrit and would remind the client not to pull on the catheter for all clients with bladder irrigation . But for this client who may be bleeding the nurse would take further action to address the problem .

A client had a vaginoplasty under epidural anesthetic. Which action by the nurse is most important? a. Ensure that the urinary catheter is securely attached to the leg. b. Instruct the client not to try to get out of bed un assisted. c. Monitor the patient's dressings and wound drainage. d. Position the Jackson-Pratt drain to the contralateral side.

ANS : B Epidural anesthesia will cause the client to not be able to move (or feel) the legs for several hours. It is important for client safety that adequate help is available prior to this client trying to get out of bed. Securing the catheter to the leg and monitoring dressings and drainage are important for any client after surgery. Positioning the drain to the contralateral side is not needed.

A client with metastatic prostate cancer has been prescribed leuprolide , a bisphosphonate , and flutamide . Which statement by the client warrants further investigation by the nurse ? a . "I go for a short walk each day , even when I am very tired." b . "My wife has noticed my eyes looking a little yellow." c . "I ordered some looser shirts to hide my enlarging breasts." d . "Now I understand my wife's hot flashes with menopause."

ANS : B Flutamide is an antiandrogen drug that can cause liver toxicity . The nurse would follow up on the statement that the client's eyes may be looking a little yellow which could indicate the onset of this adverse effect . Leuprolide can cause osteoporosis , hot flashes , and gynecomastia . The statements regarding weight - bearing exercise , enlarging breasts , and hot flashes are not cause for concern

A college student seeks information from the school's nurse about how to avoid sexually transmitted infections (STI) without abstinence as a choice. Which statement by the nurse is best? a. "Urinating after intercourse will eliminate the risk of infection." b. "A vaccine can prevent genital warts caused by some strains of the human papilloma virus (HPV)." c. "Oral contraception can prevent pregnancy and STIS." d. "Good handwashing helps prevent infection associated with STIS."

ANS : B Gardasil and Gardasil 9 are used to provide immunity for HPV types 6, 11, 16, and 18 and others that are high risk for cervical cancer and genital warts. While there is some truth that urination after intercourse may decrease the risk of infection by flushing out organisms, it does not eliminate the risk of contaminating bacteria traveling up the urethra or from skin-to-skin contact. The other statements are not accurate.

The nurse is teaching a transgender client about taking testosterone . What statement by the client indicates good understanding? a. "My periods should stop immediately." b. "Some effects can take up to a year to see." c. "I am glad I don't have to watch my diet." d. "There are very few side effects since it's a normal hormone."

ANS : B Testosterone is used as masculinizing drug therapy . Some desired effects may take up to a year to be noticed. Menses should stop within the first few months of therapy. Testosterone increases the risk of heart disease, so clients should follow a heart-healthy diet. Testosterone has several side effects, including acne, seborrhea, weight gain, edema, headaches, and possible psychosis.

A nurse is caring for a woman who had hysteroscopic surgery for uterine leiomyomas . On initial assessment , the nurse notes the following : pulse : 114 beats / min , respiratory rate : 20 breaths / minute , crackles in bilateral lung bases . What action by the nurse takes priority ? a . Assess the client for pain . b . Call the Rapid Response Team . c . Obtain an oxygen saturation . d . Delegate a temperature .

ANS : B The fluid that is used during this procedure to distend the uterine cavity can be absorbed , leading to fluid overload . This client has signs of fluid overload which can be critical . The nurse would notify the Rapid Response Team first , then perform the other actions .

A client is concerned about her irregular menstrual periods since she has increased her daily workouts at the gym to 2 hours each day . What is the nurses best response ? a. "Do you want to talk about the need for that much exercise?" b. "Exercise is healthy but can decrease body fat and cause irregular periods." c. "Bingeing and purging can cause electrolyte problems in your body." d. "Anorexic behavior can result in decreased estrogen levels."

ANS : B There needs to be a certain level of body fat and weight to maintain regular menstrual cycles. The client has only indicated that she has increased her workouts. There is no indication that she has anorexic or bingeing and purging behaviors. The question about wanting to talk about needing that much exercise sounds judgmental.

A client is admitted to the emergency department with toxic shock syndrome . Which action by the nurse is the most important ? a . Administer IV fluids to maintain fluid and electrolyte balance . b . Remove the tampon as the source of infection . C. Collect a blood specimen for culture and sensitivity . d . Transfuse the client to manage low blood count .

ANS : B The source of infection should be removed first . All of the other answers are possible interventions depending on the client's symptoms and vital signs , but removing the tampon is the priority .

The nurse is reviewing discharge plans with a client who is recovering from a cervical biopsy. Which statements indicate good understanding by the client? (Select all that apply.) a. "I can return to work this afternoon." b. "I cannot carry my toddler for 2 weeks." c. "I cannot douche until the biopsy site is healed." d. "I need to wait for about 2 weeks to have intercourse." E. "I cannot wash my perineum for 24 hours."

ANS : B , C , D The client would not douche , have intercourse , or use tampons until the biopsy site is healed . The client would rest for 24 hours after the procedure and would not lift heavy objects . The client would be taught to keep the perineum clean and dry by using antiseptic rinses and changes pads frequently .

The nurse is teaching a client about side effects and adverse reactions of a PDE5 inhibitor. What information does the nurse include? (Select all that apply.) a. Refrain from eating citrus fruit within 24 hours of taking the medication. b. Stop using this drug if your primary health care provider prescribes a nitrate. c. Do not drink alcohol before having sexual intercourse. d. Muscle cramps, nausea, and vomiting are possible if you take more than 1 pill a day. e. Take this medication within 30 to 60 minutes of having sexual intercourse. f. Change positions slowly especially if you also take an antihypertensive drug.

ANS : B , C , D , F

A 2 - month - old child has not received any immunizations Which immunizations should the nurse give ? a . DTaP , Hib , HepB , MCV , varicella b . DTaP , Hib , HepB HPV , IPV Rota C. DTaP , Hib , HepB , PCV , Rota d . DTaP , Hib , HepB , PCV , HepA

ANS : C

A client with genital herpes has painful blisters on her vulva. After teaching the client self care measures, which statement indicates the need for further education on? a. "Pouring water over my genitals will decrease the pain of urinating." b. "I will wash my hands carefully after applying ointment." c. "When I don't have lesions, I am not contagious to my sexual partner." d. "I should increase my fluid intake when I have open lesions."

ANS : C

Frequent developmental assessments are important for which reason? a. Stable developmental periods during infancy provide an opportunity to identify any delays or deficits. B. Infants need stimulation specific to the stage of development C. Critical periods of development occur during childhood. d. Child development is unpredictable and needs monitoring

ANS : C

The nurse is planning a teaching session for a young child and her parents . According to Piagets theory , the period of cognitive development in which the child is able to distinguish between concepts related to fact and fantasy , such as human beings are incapable of flying like birds , is the period of cognitive development . a Sensorimotor b . Formal operations C. Concrete operations d Preoperational

ANS : C

The nurse is working with a male client who has gynecomastia. What action by the nurse is most appropriate? a. Teach the client to perform self - breast examination. b. Review the plan for chemotherapy after surgery. c. Educate him on the side effects of tamoxifen. d. Assess his usual daily alcohol intake

ANS : C

What does the nurse need to know when observing a chronically ill child at play ? a . Play is not important to hospitalized children . b Children need to have structured play periods . C. Childrens play is a form of communication d . Play is to be discouraged because it tires hospitalized children .

ANS : C

Which children are at greater risk for not receiving immunizations ? a . Children who attend licensed daycare programs b Children entering school c . Children who are home schooled d . Young adults entering college

ANS : C

Which factor has the greatest influence on child growth and development? a. Culture b. Environment C. Genetics d. Nutrition

ANS : C