QUESTIONS AND VERIFIED DETAILED
ANSWERS
,A 2-day postpartum mother who is breastfeeding asks, "Why do I feel this tingling in my
breasts after the baby sucks for a few minutes?" Which information should the nurse provide?
A.This feeling occurs during feeding with a breast infection.
B.This sensation occurs as breast milk moves to the nipple.
C.The baby does not have good latch-on.
D.The infant is not positioned correctly. - CORRECT ANSWER B
When the mother's milk comes in, usually 2 to 3 days after delivery, women often report they
feel a tingling sensation in their nipples (B) when let-down occurs. (A, C, and D) provide
inaccurate information.
A 40-year-old office worker who is at 36 weeks' gestation presents to the occupational health
clinic complaining of a pounding headache, blurry vision, and swollen ankles. Which
intervention should the nurse implement first?
A.Check the client's blood pressure.
B.Teach her to elevate her feet when sitting.
C.Obtain a 24-hour diet history to evaluate for the intake of salty foods.
D.Assess the fetal heart rate. - CORRECT ANSWER A
The blood pressure (A) should be assessed first. Preeclampsia is a multisystem disorder, and
women older than 35 years and have chronic hypertension are at increased risk. Classic signs
include headache, visual changes, edema, recent rapid weight gain, and elevated blood
pressure. (B, C, and D) can be done if the blood pressure is normal.
,A 50-year-old man arrives at the clinic with complaints of pain on ejaculation. Which action
should the nurse implement?
A.Teach the client testicular self-examination (TSE).
B.Assess for the presence of blood in the urine.
C.Ask about scrotal pain or blood in the semen.
D.Inquire about a history of kidney stones. - CORRECT ANSWER C
Orchitis is an acute testicular inflammation resulting from recurrent urinary tract infection,
recurrent sexually transmitted disease (STD), or an indwelling urethral urinary catheter
causing pain on ejaculation, scrotal pain, blood in the semen, and penile discharge, so the
nurse should determine the presence of other symptoms (C). Although all men should
practice TSE, the client's symptoms are suggestive of an inflammatory syndrome rather than
testicular cancer (A). Although hematuria (B) is associated with renal disease or calculi (D),
the client's pain is associated with ejaculate, not urine.
A 77-year-old female client states that she has never been so large around the waist and that
she has frequent periods of constipation. Colon disease has been ruled out with a flexible
sigmoidoscopy. Which information should the nurse provide to this client?
A.As women age, they often become rounder in the middle because they do not exercise
properly.
B.Further assessment is indicated because loss of abdominal muscle tone and constipation do
not occur with aging.
, C.With age, more fatty tissue develops in the abdomen and decreased intestinal movement
can cause constipation.
D.Because there is no evidence of a diseased colon, there is no need to worry about
abdominal size - CORRECT ANSWER C
With aging, the abdominal muscles weaken as fatty tissue is deposited around the trunk and
waist. Slowing peristalsis also affects the emptying of the colon, resulting in constipation (C).
(A) is not the primary reason for the changes in body structure. (B) is not indicated because
loss of muscle tone and constipation are age-related changes. (D) dismisses the client's
concerns and does not help her understand the changes that she is experiencing.
A child is having a generalized tonic-clonic seizure. Which action should the nurse take?
A.Move objects out of the child's immediate area.
B.Quickly slip soft restraints on the child's wrists.
C.Insert a padded tongue blade between the teeth.
D.Place in the recovery position before going for help. - CORRECT ANSWER A
The first priority during a seizure is to provide a safe environment, so the nurse should clear
the area (A) to reduce the risk of trauma. The child should not be restrained (B) because this
may cause more trauma. Objects should not be placed in the child's mouth (C) because it may
pose a choking hazard. Although (D) should be implemented after the seizure, the nurse
should not leave the child during a seizure to get help.