(Detail Solutions and Resource for the test)
1. A 2-day postpartum mother who is B. This sensation occurs as breast
breastfeeding asks, "Why do I feel milk moves to the nipple.
this tingling in my breasts after the Rationale:
baby sucks for a few minutes?" When the mother's milk comes in,
Which information should the usually 2 to 3 days after delivery,
nurse provide? women often report they feel a
A. This feeling occurs during tingling sensation in their nipples (B)
feeding with a breast infection. when let-down occurs. (A, C, and D)
B. This sensation occurs as breast provide inaccurate information.
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 A. Check the client's blood pressure.
at 36 weeks' gestation presents to Rationale:
the occupational health clinic The blood pressure (A) should be
complaining of a pounding assessed first. Preeclampsia is a
headache, blurry vision, and multisystem disorder, and women
swollen ankles. Which intervention older than 35 years and have chronic
should the nurse implement first? hypertension are at increased risk.
A. Check the client's blood Classic signs include headache,
pressure. visual changes, edema, recent rapid
B. Teach her to elevate her feet weight gain, and elevated blood
when sitting. pressure. (B, C, and D) can be done
C. Obtain a 24-hour diet history to if the blood pressure is normal.
evaluate for the intake of salty
foods.
D. Assess the fetal heart rate.
3. A 50-year-old man arrives at the C. Ask about scrotal pain or blood in
clinic with complaints of pain on the semen.
ejaculation. Which action should Rationale:
the nurse implement? Orchitis is an acute testicular
A. Teach the client testicular self- inflammation resulting from
examination (TSE). recurrent urinary tract infection,
B. Assess for the presence of blood recurrent sexually transmitted
in the urine. disease (STD), or an indwelling
, C. Ask about scrotal pain or blood urethral urinary catheter causing pain
in the semen. on ejaculation, scrotal pain, blood in
D. Inquire about a history of the semen, and penile discharge, so
kidney stones. 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.
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. With aging, the abdominal muscles
Which information should the weaken as fatty tissue is deposited
nurse provide to this client? around the trunk and waist. Slowing
A. As women age, they often peristalsis also affects the emptying
become rounder in the middle of the colon, resulting in
because they do not exercise constipation (C). (A) is not the
properly. primary reason for the changes in
B. Further assessment is indicated body structure. (B) is not indicated
because loss of abdominal muscle because loss of muscle tone and
tone and constipation do not occur 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.