Question 1

The nurse reinforces education about safety modifications in the home for the spouse of a client diagnosed with Alzheimer disease. What instructions should the nurse include? Select all that apply.

Accepted Answer

When a client with Alzheimer disease is being cared for in the home, the caregiver should be instructed regarding safety modifications to ease the burden of caregiving and promote the client's independence and dignity. Injury-prevention modifications include: Arrange furniture to allow for free movement to prevent falls (Option A). Arrange furniture to allow for free movement to prevent falls (Option A). Place frequently used items within easy, visible reach of the client (Option B). Place locks on stairwells and outside doors to decrease the client's risk of falls and becoming lost during periods of wandering (Option C). Label the doors to the bathroom and other commonly used rooms to assist with environment interpretation and promote independent functioning (Option D). (Option E) Providing a night light in the sleeping area can prevent falls, aid in orientation, and decrease illusions. Educational objective: Caregivers of clients with Alzheimer disease should be taught safety modifications for the home, such as placing frequently used items within reach, arranging furniture to allow for free movement, labeling doors to commonly used rooms, providing a night light, and locking stairwell and outside doors.

Question 2

The nurse caring for a group of clients on the gynecology unit recognizes that which are at increased risk for developing breast cancer? Select all that apply.

Accepted Answer

Breast cancer is the unregulated growth of abnormal breast tissue cells and the second most common cause of cancer deaths among women. When palpated, the breast lump is usually described as hard, irregularly shaped, non-mobile, and nontender. Mammography usually detects breast cancer. Non-modifiable breast cancer risk factors include: Female sex and age ≥50 (Options D and E) First-degree relative (mother or sister) with history of breast cancer (Option A) BRCA1 and BRCA2 genetic mutations (Option B) Personal history of endometrial or ovarian cancer Menarche before age 12 or menopause after age 55 Modifiable breast cancer risk factors include: Hormone therapy with estrogen and/or progesterone (increased risk if taken after menopause) (Option E) Postmenopausal weight gain and obesity as fat cells store estrogen (Option D) History of smoking and alcohol consumption Dietary fat intake Sedentary lifestyle (Option C) A client whose menstrual period began at age 17 would not be at increased risk for breast cancer. Clients who began menarche early (before age 12) or had late menopause (after age 55) are at increased risk for breast cancer. Educational objective: Breast cancer is the second leading cause of cancer deaths among women. Breast cancer non-modifiable risk factors include female sex, advanced age, first-degree relative with breast cancer, and BRCA1 or BRCA2 genetic mutations. Modifiable risk factors include behaviors such as smoking, alcohol consumption, sedentary lifestyle, dietary fat intake, and postmenopausal weight gain and hormone therapy.

Question 3

The nurse is caring for a client in the medical-surgical unit who has delirium according to the Confusion Assessment Method assessment tool. Which of the following assessment findings are likely contributing to the client's delirium? Select all that apply.

Accepted Answer

NCLEX® CHANGE AS OF 2017 - Please note that select-all-that-apply (SATA) questions on NCLEX can now include any number of correct responses. Only ONE option or up to ALL options may be correct. UWorld questions now reflect this change. Visit NCSBN® NCLEX FAQs for more information. Delirium is characterized by an acute or fluctuating change in mental status that is often reversible and related to an underlying medical condition. Evidence-based assessment tools, such as the Confusion Assessment Method (CAM), help clinicians quickly recognize delirium. Criteria of the CAM tool include an acute or fluctuating change in mentation, inattention, disorganized thinking, and altered level of consciousness. Precipitating factors of delirium are numerous and include: Medications (eg, opioids, anticholinergics) (Option A) Electrolyte imbalances (eg, hyponatremia) (Option B) Hypoxia (Option C) Acute infection (eg, fever, positive culture) (Options D and E) Sleep deprivation Dehydration or malnutrition Metabolic disorders (eg, hypoglycemia) Nursing interventions include treating the underlying cause as prescribed to resolve delirium (eg, antibiotics, supplemental oxygen), maintaining a safe environment (eg, continuous monitoring, room near the nurses' station, bed alarm), reorienting the client frequently, promoting a regular sleep cycle, providing familiar items from home, and encouraging family and friends to stay with the client. Educational objective: The Confusion Assessment Method is an assessment tool that helps clinicians quickly recognize delirium, which is characterized by an acute or fluctuating change in mental status and is often caused by medications (eg, opioids) or an underlying medical condition (eg, hypoxia, electrolyte imbalances, infection).

Question 4

The nurse is providing teaching about contraception to a group of clients.  Which statement by the nurse is appropriate to include?

Accepted Answer

11ecbb05_ca45_b80f_b433_5911c7d09f2b_MD0009_00 Emergency contraception (EC) prevents pregnancy after unprotected intercourse. Over-the-counter EC pills (eg, high-dose levonorgestrel [Plan B One-Step]) should be taken within 3 days (72 hr) of unprotected sexual intercourse (Option C). If taken after 3 days, levonorgestrel will not harm an established pregnancy but may be less effective. Copper intrauterine device (IUD) insertion and oral ulipristal (eg, Ella) require a prescription and offer EC for up to 5 days (120 hr) after unprotected intercourse. (Option A) Backup contraception is required for 7 days after starting oral contraceptives; however, it is not required if the pill pack is started on the first day of menses. (Option B) Diaphragms are flexible latex or silicone devices that cover the cervix and create a barrier against sperm. Spermicide (eg, nonoxynol 9) is applied to the rim of the device to increase effectiveness. Neither provides reliable protection against sexually transmitted infections (STIs), and spermicide may increase the risk of HIV transmission. (Option D) Adolescents are appropriate candidates for IUD placement, which provides long-term contraception, and its effectiveness is not dependent on actions at the time of coitus. STI prevention (eg, condoms) and screening is important for all sexually active adolescents, especially those using IUDs. Educational objective: Over-the-counter emergency contraception pills (eg, high-dose levonorgestrel) are most effective within 3 days of unprotected sexual intercourse, whereas intrauterine devices (IUDs) offer emergency contraception for up to 5 days.

Question 5

The nurse is planning care for a client with suspected stroke who has just arrived at the emergency department with slurred speech, facial drooping, and right arm weakness that began 1 hour ago. Which of the following interventions should the nurse anticipate including in the initial plan of care? Select all that apply.

Accepted Answer

11ecbb05_ca41_242d_b433_8f3f2a754375_MD0009_00 Strokes may be either ischemic or hemorrhagic. Ischemic stroke occurs when circulation to parts of the brain is interrupted by occlusion of cerebral blood vessels by a thrombosis or embolus. Hemorrhagic stroke occurs when a cerebral blood vessel ruptures and bleeds into the cranial vault. Both types of stroke result in brain tissue death without prompt treatment. A client with stroke symptoms must have an immediate CT scan or MRI of the head to determine the type and location of the stroke (Option C). Determining exactly when symptoms began is essential for diagnosis and planning treatment. Thrombolytic therapy (eg, alteplase, tissue plasminogen activator [tPA]) is used to dissolve blood clots and restore perfusion to brain tissue in clients with an ischemic stroke unless contraindicated (eg, active bleeding, uncontrolled hypertension, aneurysm). It must be administered within 4.5 hours from onset of symptoms (Option E). A baseline neurologic assessment is essential for tracking ongoing neurologic symptoms that indicate improvement or complications which guide later treatments (Option D). (Options A and B) Consultation with a speech pathologist and providing the family with information about community resources are important later but not during the initial (acute) phase of stroke management. Educational objective: The initial plan of care for a client with an acute stroke should include performing baseline neurologic assessment to begin monitoring neurologic status trend, obtaining an immediate CT scan of the head to determine stroke type, and anticipating administration of thrombolytics (if indicated) within 4.5 hours of symptom onset.

Question 6

The nurse is reviewing the history of four female clients.  The nurse should recommend a Pap test to screen for cervical cancer in which client?

Accepted Answer

Pap testing allows early detection of cervical dysplasia (ie, abnormal cell growth) that may indicate cervical cancer. Human papillomavirus (HPV), an extremely common sexually transmitted infection (STI), causes almost all cases of cervical cancer. However, most women have transient infections that resolve spontaneously. Therefore, cervical cancer screening guidelines balance the need to screen for persistent (cancer-causing) infection with the knowledge that overtreating (eg, cold knife cone) may cause more harm than good. Cervical cancer screening is typically initiated at age ≥21, regardless of age at onset of sexual activity. Women age 21-29 should be screened with Pap testing every 3 years in the United States or every 1-3 years in Canada (Option B). (Option A) Regardless of sexual activity history, adolescents do not need Pap testing because HPV infection very rarely progresses to cancer in women age <21. However, testing for other STIs (eg, gonorrhea, chlamydia, HIV) is appropriate. (Option C) A client whose uterus and cervix were removed for reasons unrelated to cervical cancer does not need Pap testing if prior Pap tests were normal. (Option D) For clients who have a history of regular Pap testing with normal results, practice guidelines recommend discontinuing Pap testing at age ≥65 in the United States or age ≥70 in Canada. Educational objective: Pap testing for cervical cancer allows early detection of cervical dysplasia and is initiated at age ≥21, regardless of sexual activity history. Women who have had their uterus and cervix removed for reasons unrelated to cervical cancer and those age ≥65-70 may usually discontinue screening.

Question 7

The nurse educates a group of clients in the infertility clinic about risk factors contributing to infertility. Which factors should the nurse include in the teaching? Select all that apply.

Accepted Answer

Infertility is the inability to conceive after unprotected intercourse (ie, no contraceptive use) for >12 months. Female fertility declines as women age, with the first significant decrease seen after age 35 (Option C). Hormonal dysfunction (eg, polycystic ovarian syndrome) can cause ovarian cysts and anovulatory cycles (ie, lack of ovulation during a menstrual cycle), which impair fertility (Option D). Some sexually transmitted infections (eg, chlamydia) may be asymptomatic in females, which can delay treatment (eg, antibiotics). Untreated or recurrent infections cause inflammation (eg, pelvic inflammatory disease), scarring, and damage to the reproductive tract, leading to infertility (Option E). Endometriosis is characterized by endometrial tissue (ie, inner lining of the uterus) depositing outside the uterus. These endometrial lesions can result in chronic inflammation, pelvic pain, menstrual cycle abnormalities, and infertility (Option B). (Option A) Optimal female fertility is achieved at a BMI of 18.5-24.9 kg/m²; a BMI of 22 kg/m² is within this normal range. Very low or very high BMI is associated with hormonal dysfunction and impaired fertility. Educational objective: Infertility is the inability to conceive after unprotected intercourse for >12 months. Factors contributing to female infertility include hormonal dysfunction (eg, polycystic ovarian syndrome) with anovulation, high or low BMI, and conditions that can lead to reproductive tract scarring and damage (eg, infection, endometriosis).

Question 8

Which of these instructions is appropriate teaching for a 60-year-old woman? Select all that apply.

Accepted Answer

The average age of menopause in the United States is 50-52. Major health risks of menopause include osteoporosis and heart disease. Bisphosphonates, such as alendronate (Fosamax), risedronate (Actonel), or ibandronate (Boniva), decrease bone resorption so that loss of bone density is minimized. They must be consumed in the morning, on an empty stomach, with at least 30 minutes before other drugs. The medication is taken with a full glass of water and the client must remain upright for at least 30 minutes to aid absorption and prevent esophageal irritation (Option D). Adequate sources (both food and supplements) of calcium and vitamin D are required to build bone mass (Option A). HRT can improve bone mass and prevent osteoporosis but is associated with increased risk of thrombotic complications (deep vein thrombosis, stroke, myocardial infarction) and some cancers (breast, uterine). Therefore, it is used only in clients who have disabling hot flashes. Unilateral leg swelling is a classic symptom of venous thromboembolism (Option C). (Option B) Anemia in older adults is usually not related to lack of iron intake, especially once menstruation has stopped. Excessive iron intake can lead to iron overload, and the risk of excess iron tends to be higher with aging. (Option E) Postmenopausal bleeding or abnormal premenopausal bleeding is the most common symptom of endometrial cancer and requires follow-up. Educational objective: A postmenopausal woman (usually after age 51) is at risk for osteoporosis and heart disease. Clients should remain upright after taking a bisphosphonate and consume calcium and vitamin D for bone health. Clotting disorder is a risk with HRT. Intermittent vaginal spotting after menopause can be a sign of endometrial cancer.

Question 9

The nurse is caring for a young adult who is considering becoming pregnant.  The client expresses concern, stating, "One of my parents has Huntington disease, and I am afraid my child will get it."  How should the nurse respond?

Accepted Answer

11ecbb05_ca40_aefc_b433_270d778e66d4_MD0009_00 Huntington disease (HD) is an incurable autosomal dominant hereditary disease that causes progressive nerve degeneration, which results in impaired movement, swallowing, speech, and cognitive abilities. Chorea (involuntary, tic-like movement) is a hallmark sign. The onset of active disease is usually at age 30-50, and death from neuromuscular and respiratory complications typically occurs within 20 years of diagnosis. HD is confirmed by genetic testing. Clients who have a parent with HD and are considering having biological children should receive genetic counseling (Option A). (Option B) Autosomal dominant traits require only one copy of the affected gene (from one carrier parent) to manifest (eg, cause disease). (Option C) Although adoption may be considered, the nurse's opinion is not appropriate or therapeutic for the client. After genetic testing and further education from a genetic counselor, the client can make an informed decision about starting a family. (Option D) HD is hereditary, not spontaneous. The offspring of a client with the HD gene have at least a 50% chance of inheritance. Educational objective: Huntington disease is an incurable autosomal dominant disease that causes progressive nerve degeneration, which impairs movement, swallowing, speech, and cognitive abilities. Death typically occurs within 20 years. Clients who have a parent with this disease should receive genetic counseling, especially when planning to start a family.

Question 10

The nurse assesses a client who is 2 days postoperative breast reconstruction surgery. The client has 2 closed-suction Jackson Pratt bulb drains in place. There is approximately 10 mL of serosanguineous fluid in each one. One hour later, the nurse notices the bulbs are full of bright red drainage and measures a total output of 200 mL. What is the nurse's priority action?

Accepted Answer

11ecbb05_ca47_b3e1_b433_c7ad024834d8_MD0009_00 A closed-wound drainage system device (eg, Jackson-Pratt, Hemovac) consists of fenestrated drainage tubing connected to a flexible, vacuum (self-suction) reservoir unit. The distal end lies within the wound and can be sutured to the skin. It is usually inserted near the surgical site through a small puncture wound rather than in the surgical incision. The purpose of the drain is to prevent fluid buildup (eg, blood, serous fluid) in a closed space. Although it depends on the client and type of surgical procedure, about 80-120 mL of serosanguineous or sanguineous drainage per hour during the first 24 hours after surgery can be expected. The priority action is to notify the HCP due to the change in type and amount of drainage after the first 24 hours following surgery. Excessive bleeding and fluid collection into the closed space following breast reconstruction can greatly affect the integrity of the surgical incision, the tissue reconstruction, and wound healing (Option A). (Option B) Opening the bulb does not release excessive negative pressure. It would release all negative pressure, drainage would cease, and even more fluid would collect in the closed space, compromising the integrity of the incision even further. (Option C) Recording the amount of wound drainage on the output record is an appropriate intervention. However, it is not the priority action. (Option D) Although repositioning the client could affect the amount of drainage, it is not likely as drainage is maintained by negative pressure, not gravity. Educational objective: Although it depends on the type of surgical procedure performed, about 80-120 mL of serosanguineous or sanguineous drainage per hour for the first 24 hours following surgery can be expected. The nurse should notify the HCP if the drainage in the Jackson-Pratt closed-wound drainage device changes from serosanguineous to sanguineous and if the amount increases significantly after the first 24 hours following surgery.

Question 11

A client with diabetes mellitus is admitted to the surgical unit after a vaginal hysterectomy. The client received 6 units of regular insulin subcutaneously and metoprolol 50 mg by mouth in the post-anesthesia care unit. Which statement by the unlicensed assistive personnel would require immediate action by the nurse?

Accepted Answer

The nurse should take immediate action when a client recovering from a vaginal hysterectomy saturates more than one perineal pad in an hour. The nurse should further assess the client and report these findings and excessive vaginal bleeding to the health care provider (HCP). (Option B) The client should be encouraged to perform leg exercises while in bed to promote circulation and prevent deep vein thrombosis (DVT). (Option C) The client's voiding of 500 mL of straw-colored urine is a normal finding. (Option D) The client received metoprolol, a beta-adrenergic blocker, which slows the heart rate. If the heart rate is below 60 (or prescribed rate) prior to medication administration, the nurse should withhold further metoprolol and contact the HCP. The vital signs do not require immediate action by the nurse. Educational objective: A client recovering from a vaginal hysterectomy should be monitored for excessive vaginal bleeding, urinary retention, backache, decreased urinary output, and the development of signs and symptoms of complications such as DVT.

Question 12

Which statement is most important to emphasize when teaching a 40-year-old female client newly diagnosed with fibrocystic breast changes?

Accepted Answer

One of the most common benign breast disorders is fibrocystic breast changes. Fibrocystic changes correlate to estrogen/progesterone hormone fluctuations during the menstrual cycle. Clients may report cysts, nodules, or lumps that are more tender, swollen, and/or noticeable prior to menses. The condition typically resolves after menopause. The nurse instructs the client on breast self-awareness and emphasizes that any noncyclic breast changes (ie, not related to the menstrual cycle) may indicate malignancy (ie, cancer) and should be immediately reported to the health care provider (HCP) (Option A). (Option B) Clients should be instructed that cyclic pain and swelling may be reduced by decreasing caffeine and sodium intake; taking vitamins E, A, and B complex; wearing a support bra; utilizing cold compresses; and taking nonsteroidal anti-inflammatory drugs (eg, ibuprofen). (Option C) Clients age >40 should receive yearly clinical breast examinations by an HCP and practice breast self-awareness. Emphasis is placed on the importance of reporting any suspicious breast changes. (Option D) The client should be taught that fibrocystic breast changes are benign and do not increase the risk of breast cancer; however, reporting noncyclic changes is a higher priority. Educational objective: Fibrocystic breast changes are cyclic changes that occur as a result of heightened responses to estrogen and progesterone. Clients should be taught the need to report noncyclic changes to the health care provider, as well as symptom management, breast self-awareness, and the importance of regular clinical breast examinations.

Question 13

A 14-year-old is seen in the sexually transmitted disease (STD) outpatient department and diagnosed with gonorrhea. The client tells the nurse of having sexual relations with only a 19-year-old partner. What is the best response by the nurse?

Accepted Answer

To avoid re-infection with gonorrhea, it is essential that the client's partner be tested and treated. During the visit, the nurse should counsel the client about the importance of partner evaluation and treatment and the likely recurrence of the infection if the partner refuses to be treated. The client should avoid sexual relations until treatment is completed and the client and partner no longer have symptoms. (Option B) A 19-year-old having sexual relations with a 14-year-old is considered statutory rape and is reportable to child protective services or local law enforcement. However, it is most important in this situation to ensure that the client and partner receive appropriate testing and effective treatment. If the client is told that the two are going to be reported to the local authorities, there is a high probability that the client will leave the clinic without being treated and the partner will never come in. (Option C) Parental consent for treatment of an STD is not required in this situation. All 50 states and the District of Columbia allow minors (age 12-14 or older) to consent to testing and treatment. (Option D) This is appropriate information to provide to the client. However, it is most important for the nurse to assess the status of the client's partner. Educational objective: In addition to the medical treatment of gonorrhea and other STDs, it is crucial for the nurse to counsel the client about the need for partner evaluation and treatment to prevent re-infection and disease transmission.

Question 14

The nurse educates the caregiver of a client with Alzheimer disease about maintaining the client's safety. Current symptoms include occasional confusion and wandering. Which of the following responses by the caregiver show correct understanding? Select all that apply.

Accepted Answer

Alzheimer disease (AD) is a form of dementia that causes progressive decline of cognitive and physical abilities. The nurse should educate the client/caregiver to prepare for current and future safety needs. Interventions evolve to meet client needs at each stage of disease progression. Safety promotion for the client with moderate AD includes: Keyed deadbolts (with keys removed) and close supervision to provide a controlled environment for wandering (Option C) Medical identification/location devices (eg, bracelets, shoe inserts) in case the client wanders outside the designated area (Option B) Decreased water heater temperature and "hot" and "cold" labels on faucets to prevent burns Household hazards (eg, gas appliances, rugs, toxic chemicals) removed to prevent injury (Option E) Grab bars installed in showers and tubs (Option A) (Option D) All medications should be out of the client's reach or locked away. A confused person may not remember the day of the week and take more or less medication than prescribed. Educational objective: For clients with moderate Alzheimer disease, caregivers should provide a controlled environment for safe wandering (eg, throw rugs and clutter removed, exterior doors secured), and the client should wear an identification/location device (eg, bracelet). All medications should be out of reach or locked away. Hazards (eg, gas appliances, rugs, toxic chemicals) should be removed. Grab bars should be installed in showers and tubs.

Question 15

A client is being discharged home after an open radical prostatectomy. Which statement indicates a need for further teaching?

Accepted Answer

11ecbb05_ca46_2d40_b433_435ba8a9a229_MD0009_00 Following open radical prostatectomy, any rectal interventions such as suppositories or enemas must be avoided to prevent stress on the suture lines and problems with healing in the surgical area. The client should not strain when having a bowel movement for these reasons. Therefore, interventions to prevent constipation are an important part of postoperative care and discharge teaching. Prevention of constipation is particularly important while the client remains on opioid analgesics, which can cause constipation (Option D). (Option A) Fluid intake should be encouraged in this client. (Option B) The client is at risk for postoperative deep vein thrombosis and pulmonary embolism. Ambulation is an important part of preventing these serious surgical complications. Ambulation will also help reduce constipation. (Option C) The client who goes home with an indwelling catheter should learn how to clean around the catheter at the urinary meatus with warm water and soap to prevent infection. Educational objective: Clients who have had an open radical prostatectomy for prostate cancer should avoid anything that could cause strain on the rectal area. Straining, suppositories, and enemas are contraindicated in these clients, and interventions should be implemented to prevent constipation.

Question 16

The nurse provides education for caregivers of a client with Alzheimer disease. Which instructions should the nurse include? Select all that apply.

Accepted Answer

Strategies for caring for clients with Alzheimer disease address progressive memory loss and declining ability to communicate, think clearly, and perform activities of daily living. Caregivers should also learn to manage clients' problematic behavior and mood swings. Therapeutic guidelines include: Use distraction and redirection (eg, going for a walk) to manage agitation (Option C). Speak slowly and use simple words and yes-or-no questions. Do not try to rationalize with the client. Use visual cues when giving directions. Interact with the client as an adult, even as the client regresses to childlike affect and behavior; respect client dignity by avoiding use of pet names (eg, "honey," "sweetie," "darling") (Option D). Break down complex activities into steps with simple instructions. Decrease the client's anxiety by limiting the number of choices (Option B). (Option A) Allow plenty of time for task completion. The client cannot process information rapidly, and hurrying or rushing can cause agitation or anxiety. (Option E) Ask questions that can be answered with yes, no, or very few words. Do not ask open-ended questions, which can overwhelm the client and cause increased stress and frustration. Educational objective: Caregivers for clients with Alzheimer disease should communicate with the client using yes-or-no questions and simple, step-by-step instructions; treat the client as an adult; limit the number of choices; and allow plenty of time for task completion. Agitated clients can be redirected with new activities (eg, going for a walk).

Question 17

The nurse is caring for an adolescent newly diagnosed with a chlamydial infection. After administering a one-time dose of azithromycin, the nurse understands that which of the following client statements indicate a correct understanding of client teaching? Select all that apply.

Accepted Answer

Chlamydia is the most common sexually transmitted infection and is diagnosed frequently among women, adolescents, and those with multiple sexual partners. Many clients are asymptomatic or have minor symptoms (eg, spotting after sex, dysuria, abnormal vaginal discharge) but can still transmit the infection (Option C). Therefore, all sexually active women age <25 and any client age ≥25 at high risk (eg, new or several sexual partners) are screened annually for chlamydia and gonorrhea (Option D). The client's sexual partners should also receive treatment to prevent transmission and reinfection (Option E). If not treated appropriately, chlamydia can ascend the female genital tract, producing serious complications such as pelvic inflammatory disease and infertility (Option A). Clients should also be instructed in general safe sex practices (eg, using condoms, avoiding multiple partners) to help prevent transmission of sexually transmitted infections. Clients should be taught to abstain from sexual intercourse for 7 days after initiation of drug therapy (eg, single dose of azithromycin, 7 days of doxycycline). This client received treatment today and therefore must wait 7 days before resuming intercourse (Option B). Educational objective: Clients with a chlamydial infection may be asymptomatic or experience minor symptoms (eg, spotting after sex, dysuria, abnormal vaginal discharge). Clients should abstain from sexual intercourse for 7 days after antibiotic treatment is initiated and until all sexual partners have completed treatment to prevent transmission and serious complications. Sexually active clients age <25 or those age ≥25 at high risk should be screened annually.

Question 18

A nurse is teaching a client with a surgically repaired undescended testis about testicular self-examination (TSE). Which instructions should be included in the teaching? Select all that apply.

Accepted Answer

11ecbb05_ca49_afb3_b433_c90a6a45143c_MD0009_00 Testicular cancer is the most common form of cancer in men age 15-35. When diagnosed early, it is highly curable. Clients at high risk for developing a tumor (eg, history of undescended testis) are encouraged to perform a monthly TSE. Client instructions for a TSE include:Perform TSE monthly on the same day (easy to remember) Perform TSE while taking a warm shower or bath as warm temperatures will relax the scrotal tissue and make the testis hang lower in the scrotum Use both hands to feel each testis separately Palpate each testicle gently, using the thumb and first 2 fingers Check that the testicle is normally egg-shaped and movable with a smooth surface The clinical findings that should be reported to the health care provider include: Painless, hardened lump on testes Scrotal swelling or heaviness Dull ache in pelvis or scrotum (Option C) It is normal for one testicle to be slightly larger or hang lower than the other. Some people may also confuse epididymis (small coiled tube) as a small lump at the beginning. These do not need to be reported. Educational objective: Clients with a history of undescended testis or testicular tumor are encouraged to perform a monthly TSE. It is best done during a warm shower. The first indication of testicular cancer may be a painless, hardened lump on the testes or a feeling of scrotal heaviness.

Question 19

The nurse is caring for a client in the immediate postoperative period following a carotid endarterectomy. The client is drowsy with slurred speech. Which assessment finding would cause the nurse to notify the healthcare provider immediately?

Accepted Answer

11ecbb05_ca43_bc3e_b433_9bbe5e6a3057_MD0009_00 A carotid endarterectomy is a surgical procedure performed to remove plaque from the carotid artery to improve cerebral perfusion. The nurse must closely assess for signs of new or worsening alterations in neurologic status, as surgical manipulation of arteries and blood flow increases the risk of stroke. Monitoring the client's neurologic status postoperatively can be challenging, as the effects of anesthesia degrade the neurologic examination. Nurses should use the FAST acronym to assess for stroke: Facial drooping: Numbness or droopiness on one side of the face Arm weakness: Weakness or drifting of one arm when raised to shoulder level (Option C) Speech difficulties: Slurring of words, incomprehensible speech, inability to understand others Time: Notation of the time of symptom onset, which is critical for guiding treatment (Option A) Diminished gag reflex is common after anesthesia and endotracheal tube removal. The gag reflex should return as the client awakens. (Option B) Individuals recovering from anesthesia may have alterations in mood or affect (eg, agitation, anxiety, tearfulness) that will resolve as anesthesia wears off. (Option D) Drowsiness and somnolence during purposeful interactions (ie, following commands) are expected after anesthesia. Educational objective: Following a carotid endarterectomy, the client should be monitored for alterations in mental status that are unexpected in the context of typical postanesthesia symptoms (eg, diminished gag reflex, altered affect, drowsiness). The FAST assessment (Facial drooping, Arm weakness or drift, Speech difficulties, Time) assists with identifying alterations that may indicate stroke.

Question 20

The nurse employed in a woman's health care clinic would be most concerned about which client statement?

Accepted Answer

11ecbb05_ca48_5022_b433_013d38022d97_MD0009_00 The nurse would be most concerned about the client who describes symptoms of inflammatory breast cancer. In this aggressive form of cancer, breast lymph channels are blocked by cancer cells, creating breast tissue that becomes red, warm, and has an orange peel (peau d'orange), pitting appearance on the skin surface. The nurse would be most concerned about this client and make an immediate referral to the health care provider for examination and evaluation. (Option A) Clients usually describe lumps related to fibroadenoma, a benign breast disorder, as small, round, painless, mobile lumps with no breast tissue retraction or discharge. (Option B) Further assessment is needed to determine if the client is at risk for developing mastitis. Mastitis may develop in lactating women when the nipples become dry and crack. The cracked nipples may provide a portal of entry for microorganisms, especially Staphylococcus. The client should be taught appropriate care of the breast during lactation. The client diagnosed with mastitis will experience warm, red, painful, and edematous breasts. (Option D) Clients usually describe fibrocystic breast nodules as soft, movable nodules that change size at various times during the menstrual cycle. Fibrocystic breast changes are a common benign breast disorder. Educational objective: Inflammatory breast disease is an aggressive breast cancer with symptoms of red, warm, peau d'orange breast tissue. A breast mass may or may not be present.

Exam 1: Adult Health

The nurse reinforces education about safety modifications in the home for the spouse of a client diagnosed with Alzheimer disease. What instructions should the nurse include? Select all that apply.

The nurse caring for a group of clients on the gynecology unit recognizes that which are at increased risk for developing breast cancer? Select all that apply.

The nurse is caring for a client in the medical-surgical unit who has delirium according to the Confusion Assessment Method assessment tool. Which of the following assessment findings are likely contributing to the client's delirium? Select all that apply.

The nurse is providing teaching about contraception to a group of clients. Which statement by the nurse is appropriate to include?

The nurse is reviewing the history of four female clients. The nurse should recommend a Pap test to screen for cervical cancer in which client?

The nurse educates a group of clients in the infertility clinic about risk factors contributing to infertility. Which factors should the nurse include in the teaching? Select all that apply.

Which of these instructions is appropriate teaching for a 60-year-old woman? Select all that apply.

The nurse is caring for a young adult who is considering becoming pregnant. The client expresses concern, stating, "One of my parents has Huntington disease, and I am afraid my child will get it." How should the nurse respond?

Which statement is most important to emphasize when teaching a 40-year-old female client newly diagnosed with fibrocystic breast changes?

A 14-year-old is seen in the sexually transmitted disease (STD) outpatient department and diagnosed with gonorrhea. The client tells the nurse of having sexual relations with only a 19-year-old partner. What is the best response by the nurse?

The nurse educates the caregiver of a client with Alzheimer disease about maintaining the client's safety. Current symptoms include occasional confusion and wandering. Which of the following responses by the caregiver show correct understanding? Select all that apply.

A client is being discharged home after an open radical prostatectomy. Which statement indicates a need for further teaching?

The nurse provides education for caregivers of a client with Alzheimer disease. Which instructions should the nurse include? Select all that apply.

The nurse is caring for an adolescent newly diagnosed with a chlamydial infection. After administering a one-time dose of azithromycin, the nurse understands that which of the following client statements indicate a correct understanding of client teaching? Select all that apply.

A nurse is teaching a client with a surgically repaired undescended testis about testicular self-examination (TSE) . Which instructions should be included in the teaching? Select all that apply.

The nurse is caring for a client in the immediate postoperative period following a carotid endarterectomy. The client is drowsy with slurred speech. Which assessment finding would cause the nurse to notify the healthcare provider immediately?

The nurse employed in a woman's health care clinic would be most concerned about which client statement?