ACCURATE RESPONSES FULL SOLUTION
◉ The nurse assists with the reinforcement of information about
breast self-examination to a group of college students. A female
student asks when to perform the monthly exam. The appropriate
reply by the nurse should include which statement?
1"Ovulation, or midcycle is the best time to detect changes."
2"Do the exam at the same time every month."
3"Right after the period, when your breasts are less tender."
4"The first of every month, because it will be easiest to remember.".
Answer: 3
◉ The nurse is caring for a 75 year-old client with type 2 diabetes
mellitus. The client should be instructed to contact the outpatient
clinic immediately if which findings are present?
1An open wound on the heel with minimal discomfort
2Occasional hiccups and sneezing
3Sustained insomnia and daytime fatigue
4Persistent dryness and itching of the perineal area. Answer: 1An
open wound on the heel with minimal discomfort-
,◉ A pregnant woman has been advised to alter her diet during
pregnancy by increasing the intake of protein and vitamin C to meet
the needs of the growing fetus. Which diet choice would best meet
the woman's needs?
1. 1 cup of macaroni, three-fourths cup of peas, glass whole milk,
medium pear
2. Scrambled egg, hash browned potatoes, one-half glass of
buttermilk, large nectarine
3. 3 oz. chicken, one-half cup of corn, lettuce salad, small banana
4. Beef, one-half cup of lima beans, glass of skim milk, three-fourths
cup of strawberries. Answer: 4. Beef, one-half cup of lima beans,
glass of skim milk, three-fourths cup of strawberries -
◉ A nurse is taking a health history from parents of a child admitted
with possible Reye's syndrome. Which recent illness should the
nurse recognize as being associated with an increased the risk for
the development of Reye's syndrome?
1. Varicella
2. Meningitis
3. Hepatitis
4. Rubeola. Answer: 1. Varicella -
◉ A Native American chief visits his newborn son and performs a
traditional ceremony that involves feathers and chanting. The nurse
comments to a colleague: "I wonder if he has any idea how
,ridiculous he looks - he's a grown man!" The nurse's comment is an
example of what type of attitude?
1. Prejudice
2. Ethnocentrism
3. Discrimination
4. Stereotyping. Answer: 1. Prejudice-
◉ A nursing student asks the licensed practical nurse (LPN) to
explain the forces that drive health care reform. When responding to
the student's question, what information should the nurse
emphasize?
1. Increased competition between health care insurers
2. Increase in health care spending that's growing faster than the
economy
3. Increase in the population who have health insurance
4. Increase in spending for end-of-life treatment. Answer: 2
◉ A child is admitted to the unit with the suspected diagnosis of
pertussis (whooping cough). What is the priority nursing
intervention for this child?
1. Maintain hydration and encourage fluids
2. Implement droplet precautions
3. Monitor respiratory rate and oxygen saturation
4. Anti- infective therapy. Answer: 2
, ◉ A client has an indwelling catheter with continuous bladder
irrigation after undergoing a transurethral resection of the prostate
(TURP) 12 hours ago. Which finding at this time should be reported
to the registered nurse (RN) charge nurse?
1Complaints for the feeling of pulling on the urinary catheter
2Light, pink to clear urine
3Occasional suprapubic cramping
4Minimal drainage into the urinary collection bag. Answer:
4Minimal drainage into the urinary collection bag
◉ A nurse is caring for a woman two hours after a vaginal delivery.
Documentation indicates that the membranes ruptured 36 hours
prior to delivery. Which of these nursing diagnoses should the nurse
expect the charge nurse to list as a priority at this time?
1Risk for fluid volume deficit
2Risk for excessive bleeding
3Risk for infection -
4Altered tissue perfusion. Answer: 3
◉ A 14 month-old child ingests a half a bottle of baby aspirin (81
mg) tablets. Which finding should a nurse expect to see in the child?
1Hypothermia
2Nausea and vomiting