,
, in the urine. an indwelling urethral urinary catheter
C. Ask about scrotal pain or blood causing pain on ejaculation, scrotal
in the semen. pain, blood in the semen, and penile
D. Inquire about a history of kidney discharge, so the nurse should
stones. 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.
4. A 77-year-old female client states C. With age, more fatty tissue
that she has never been so large develops in the abdomen and
around the waist and that she has decreased intestinal movement can
frequent periods of constipation. cause constipation.
Colon disease has been ruled out Rationale:
with a flexible sigmoidoscopy. Which With aging, the abdominal muscles
information should the nurse provide weaken as fatty tissue is deposited
to this client? around the trunk and waist. Slowing
A. As women age, they often become peristalsis also affects the emptying of
rounder in the middle because they the colon, resulting in constipation (C).
do not exercise properly. (A) is not the primary reason for the
B. Further assessment is indicated changes in body structure. (B) is not
because loss of abdominal muscle indicated because loss of muscle tone
tone and constipation do not occur and constipation are age-related
with aging. changes. (D) dismisses the client's
C. With age, more fatty tissue concerns and does not help her
develops in the abdomen and understand the changes that she is
decreased intestinal movement can experiencing.
cause constipation.
D. Because there is no evidence of a
diseased colon, there is no need to
worry about abdominal size.
5. According to Erikson, which client D. A 75-year-old woman who wishes
should the nurse identify as having her friends were still alive so she could
difficulty completing the change some of the choices she made
developmental stage of older adults? over the years
, A. A 60-year-old man who tells the Rationale:
nurse that he is feeling fine and The older woman who wishes she
really does not need any help from could change the choices she has made
anyone in her lifetime is expressing despair
B. A 78-year-old widower who has and is still searching for integrity (D).
come to the mental health clinic for The nurse uses Erikson stages of
counseling after the recent death of development over the life span to
his wife assess an older client's adjustment to
C. An 81-year-old woman who states aging and plans teaching strategies to
that she enjoys having her assist the clients attain integrity versus
grandchildren visit but is usually despair. (A, B, and C) are normal
glad when they go home developmental tasks of older adults.
D. A 75-year-old woman who wishes
her friends were still alive so she
could change some of the choices she
made over the years
6. After administration of an 0730 dose A. Ensure that the client receives
of Humalog 50/50 insulin to a client breakfast within 30 minutes.
with diabetes mellitus, which nursing Rationale:
action has the highest priority? Insulin 50/50 contains 50% regular
A. Ensure that the client receives and 50% NPH insulin. Therefore, the
breakfast within 30 minutes. onset of action is within 30 minutes
B. Remind the client to have a and the nurse's priority action is to
midmorning snack at 1000. ensure that the client receives a
C. Discuss the importance of a breakfast tray to avoid a hypoglycemic
midafternoon snack with the client. reaction (A). (B, C, and D) are also
D. Explain that the client's capillary important nursing actions but are of
glucose will be checked at 1130. less immediacy than (A).
7. The antigout medication allopurinol A. "I take aspirin for my pain."
(Zyloprim) is prescribed for a client newly Rationale:
diagnosed with gout. Which comment by The client should be taught to
the client warrants intervention by the avoid aspirin (A) because the
nurse? ingestion of aspirin or diuretics
A. "I take aspirin for my pain." can precipitate an attack of
B. "I frequently eat fruit and drink fruit gout. (B, C, and D) are all
juices." appropriate for the treatment of
C. "I drink a great deal of water, so I have gout. The client's urinary pH
to get up at night to urinate." can be increased by the intake
D. "I observe my skin daily to see if I have of alkaline ash foods, such as
, in the urine. an indwelling urethral urinary catheter
C. Ask about scrotal pain or blood causing pain on ejaculation, scrotal
in the semen. pain, blood in the semen, and penile
D. Inquire about a history of kidney discharge, so the nurse should
stones. 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.
4. A 77-year-old female client states C. With age, more fatty tissue
that she has never been so large develops in the abdomen and
around the waist and that she has decreased intestinal movement can
frequent periods of constipation. cause constipation.
Colon disease has been ruled out Rationale:
with a flexible sigmoidoscopy. Which With aging, the abdominal muscles
information should the nurse provide weaken as fatty tissue is deposited
to this client? around the trunk and waist. Slowing
A. As women age, they often become peristalsis also affects the emptying of
rounder in the middle because they the colon, resulting in constipation (C).
do not exercise properly. (A) is not the primary reason for the
B. Further assessment is indicated changes in body structure. (B) is not
because loss of abdominal muscle indicated because loss of muscle tone
tone and constipation do not occur and constipation are age-related
with aging. changes. (D) dismisses the client's
C. With age, more fatty tissue concerns and does not help her
develops in the abdomen and understand the changes that she is
decreased intestinal movement can experiencing.
cause constipation.
D. Because there is no evidence of a
diseased colon, there is no need to
worry about abdominal size.
5. According to Erikson, which client D. A 75-year-old woman who wishes
should the nurse identify as having her friends were still alive so she could
difficulty completing the change some of the choices she made
developmental stage of older adults? over the years
, A. A 60-year-old man who tells the Rationale:
nurse that he is feeling fine and The older woman who wishes she
really does not need any help from could change the choices she has made
anyone in her lifetime is expressing despair
B. A 78-year-old widower who has and is still searching for integrity (D).
come to the mental health clinic for The nurse uses Erikson stages of
counseling after the recent death of development over the life span to
his wife assess an older client's adjustment to
C. An 81-year-old woman who states aging and plans teaching strategies to
that she enjoys having her assist the clients attain integrity versus
grandchildren visit but is usually despair. (A, B, and C) are normal
glad when they go home developmental tasks of older adults.
D. A 75-year-old woman who wishes
her friends were still alive so she
could change some of the choices she
made over the years
6. After administration of an 0730 dose A. Ensure that the client receives
of Humalog 50/50 insulin to a client breakfast within 30 minutes.
with diabetes mellitus, which nursing Rationale:
action has the highest priority? Insulin 50/50 contains 50% regular
A. Ensure that the client receives and 50% NPH insulin. Therefore, the
breakfast within 30 minutes. onset of action is within 30 minutes
B. Remind the client to have a and the nurse's priority action is to
midmorning snack at 1000. ensure that the client receives a
C. Discuss the importance of a breakfast tray to avoid a hypoglycemic
midafternoon snack with the client. reaction (A). (B, C, and D) are also
D. Explain that the client's capillary important nursing actions but are of
glucose will be checked at 1130. less immediacy than (A).
7. The antigout medication allopurinol A. "I take aspirin for my pain."
(Zyloprim) is prescribed for a client newly Rationale:
diagnosed with gout. Which comment by The client should be taught to
the client warrants intervention by the avoid aspirin (A) because the
nurse? ingestion of aspirin or diuretics
A. "I take aspirin for my pain." can precipitate an attack of
B. "I frequently eat fruit and drink fruit gout. (B, C, and D) are all
juices." appropriate for the treatment of
C. "I drink a great deal of water, so I have gout. The client's urinary pH
to get up at night to urinate." can be increased by the intake
D. "I observe my skin daily to see if I have of alkaline ash foods, such as
