Answers With Rtionale(Summer 2022)
1 A 2-day postpartum mother who is B. Assess for the presence of blood
. 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.
2 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.
3 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. This sensation occurs as breast multisystem disorder, and women older
milk moves to the nipple. than 35 years and have chronic
Rationale: hypertension are at increased risk.
When the mother's milk comes in, Classic signs include headache, visual
usually 2 to 3 days after delivery, changes, edema, recent rapid weight
women often report they feel a gain, and elevated blood pressure. (B,
tingling sensation in their nipples (B) C, and D) can be done if the blood
when let- down occurs. (A, C, and D) pressure is normal.
provide inaccurate information.
C. Ask about scrotal pain or blood
in the semen.
Rationale:
A. Check the client's blood Orchitis is an acute testicular
pressure. Rationale: inflammation resulting from recurrent
The blood pressure (A) should be urinary tract infection, recurrent
assessed first. Preeclampsia is a sexually transmitted disease (STD), or
, in the urine. developmental stage of older
C. Ask about scrotal pain or adults?
blood in the semen.
D. Inquire about a history of
kidney stones.
4 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.
5 According to Erikson, which client
. should the nurse identify as having
difficulty completing the
, 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.
C. With age, more fatty tissue
develops in the abdomen and
decreased intestinal movement can
cause constipation.
Rationale:
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.
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