Nursing Elites

1. Which instruction should be given in a health education class regarding testicular cancer?

• A. All males should perform a testicular exam after a warm bath or shower.
• B. Testicular exams should be performed on a daily basis.
• C. Reddening or darkening of the scrotum is a normal finding.
• D. Testicular exams should be performed after a warm bath or shower.

Correct answer: D

Rationale: The correct instruction for testicular cancer education is that testicular exams should be performed after a warm bath or shower as it relaxes the scrotum and makes the exam easier. Testicular exams should be done monthly by all men starting around age 15, not after the age of 30 (Choice A) or on a daily basis (Choice B), which is unnecessary and may lead to unnecessary anxiety. Reddening or darkening of the scrotum is not a normal finding (Choice C) and should be reported to a healthcare provider for further evaluation.

2. A client is admitted for observation following an unrestrained motor vehicle accident. A bystander stated that he lost consciousness for 1-2 minutes. On admission, the client's Glasgow Coma Scale (GCS) was 14. The GCS is now 12. The nurse should:

• A. Re-assess in 15 minutes
• B. Stimulate the client with a sternal rub
• C. Administer Tylenol with codeine for a headache
• D. Notify the physician

Correct answer: D

Rationale: A decrease in the Glasgow Coma Scale (GCS) score from 14 to 12 indicates a significant neurological change in the client's condition. This change can be indicative of a deterioration in the client's neurological status, possibly due to intracranial bleeding or swelling. It is crucial for the nurse to notify the physician immediately to ensure prompt evaluation and intervention. Re-assessing in 15 minutes or stimulating the client with a sternal rub are not appropriate actions in this situation as they do not address the underlying cause of the decrease in GCS. Administering Tylenol with codeine for a headache is also not recommended without further assessment and evaluation of the client's condition.

3. A 70-year-old male who is recovering from a stroke exhibits signs of unilateral neglect. Which behavior is suggestive of unilateral neglect?

• A. The client is observed shaving only one side of his face.
• B. The client is unable to distinguish between two tactile stimuli presented simultaneously.
• C. The client is unable to complete a range of vision without turning his head side to side.
• D. The client is unable to carry out cognitive and motor activity at the same time.

Correct answer: A

Rationale: Unilateral neglect is a condition where a person ignores one side of their body. In this case, the behavior of shaving only one side of the face indicates neglect of the other side. This behavior is suggestive of unilateral neglect as the individual is failing to attend to one side of their body. Choices B, C, and D are not associated with unilateral neglect. Choice B refers to tactile agnosia, a condition where a person cannot recognize objects by touch, not related to ignoring one side of the body. Choice C describes a visual field cut, which is a different visual deficit. Choice D relates to dual-task interference, not specific to ignoring one side of the body.

4. The factor that most determines drug distribution is:

• A. vascular perfusion of the tissue or organ.
• B. salt form.
• C. drug interactions.
• D. steady state.

Correct answer: A

Rationale: The correct answer is 'vascular perfusion of the tissue or organ.' Drug distribution is primarily determined by how well the circulatory system delivers the drug to various tissues and organs. Adequate perfusion ensures proper distribution of the drug throughout the body. While the salt form (choice B), drug interactions (choice C), and steady state (choice D) can influence drug efficacy and metabolism, they are not as crucial as vascular perfusion for the initial distribution of a drug.

5. A client has a 10% dextrose in water IV solution running. He is scheduled to receive his antiepileptic drug, phenytoin (Dilantin), at this time. The nurse knows that the phenytoin:

• A. is given after the D10W is finished.
• B. should be given at the time it is due in the medication port closest to the client.
• C. can be piggybacked into the D10W solution now.
• D. is incompatible with dextrose solutions.

Correct answer: D

Rationale: Phenytoin is incompatible with dextrose solutions as they will precipitate when mixed together. Therefore, it should not be piggybacked into the D10W solution or given through the same port. Instead, normal saline should be used to flush before and after administering phenytoin to prevent any interaction with the dextrose solution. Delaying the administration of an antiepileptic drug like phenytoin to maintain therapeutic blood levels is not recommended, so it should not be given after the D10W is finished or based on the medication port closest to the client. Choice A is incorrect because administering phenytoin after the D10W is finished is not the correct approach due to the incompatibility with dextrose solutions. Choice B is incorrect as the timing of phenytoin administration should not be based on the medication port closest to the client but on compatibility considerations. Choice C is incorrect as piggybacking phenytoin into the D10W solution is not advisable due to the incompatibility issue.

Similar Questions