NLE...reviewer compiled ZudotaMiko boomThe nurse is instructing a premenopausal woman about breast self-examination. The nurse should tell the client to do her self-examination:at the end of her menstrual cycle.on the same day each month.on the 1st day of the menstrual cycle.immediately after her menstrual period.RATIONALE: Premenopausal women should do their self-examination immediately after the menstrual period, when the breasts are least tender and least lumpy. On the 1st and last days of the cycle, the woman's breasts are still very tender. Postmenopausal women, because their bodies lack fluctuation of hormone levels, should select one particular day of the month to do breast self-examination.The nurse is teaching a client with a history of atherosclerosis. To decrease the risk of atherosclerosis, the nurse should encourage the client to:avoid focusing on his weight.increase his activity level.follow a regular diet.continue leading a high-stress lifestyle.RATIONALE: The client should be encouraged to increase his activity level. Maintaining an ideal weight; following a low-cholesterol, low-sodium diet; and avoiding stress are all important factors in decreasing the risk of atherosclerosisThe nurse is providing teaching to a client who's at risk for coronary artery disease (CAD). The nurse tells the client that CAD has many risk factors. Risk factors that can be controlled or modified include:gender, obesity, family history, and smoking.inactivity, stress, gender, and smoking.obesity, inactivity, diet, and smoking.stress, family history, and obesity.RATIONALE: The risk factors for coronary artery disease that can be controlled or modified include obesity, inactivity, diet, stress, and smoking. Gender and family history are risk factors that can't be controlled.The nurse is caring for a client who underwent a subtotal gastrectomy. To manage dumping syndrome, the nurse should advise the client to:restrict fluid intake to 1 qt (1,000 ml)/day.drink liquids only with meals.not drink liquids 2 hours before meals.drink liquids only between meals.The client most at risk for sensory overload is:A.a 28-year-old pregnant client with complaints of nausea, vomiting, and fatigue.B. an 80-year-old client in the intensive care unit (ICU).C. a 4-year-old in a clinic for immunizations.D. a 72-year-old client having dressings changed by a home care nurse.RATIONALE: Sensory overload is a condition in which the central nervous system receives much more auditory, visual, or other environmental stimuli per time frame than can be processed effectively. Because of all the monitors, beeping sounds, lights, and constant activity, an 80-year-old in the ICU is most at risk for sensory overload. The pregnant client is experiencing symptoms that aren't environmental stimuli. The other choices deal with less overwhelming stimuli.

RATIONALE: A client who experiences dumping syndrome after a subtotal gastrectomy should be advised to ingest liquids between meals rather than with meals. Taking fluids between meals allows for adequate hydration, reduces the amount of bulk ingested with meals, and aids in preventing rapid gastric emptying. There's no need to restrict the amount of fluids, just the time when the client drinks fluids. Drinking liquids with meals increases the risk of dumping syndrome by increasing the amount of bulk and stimulating rapid gastric emptying. Small amounts of water are allowable before meals.The nurse is teaching a group of women to perform breast self-examination. The nurse should explain that the purpose of performing the examination is to discover:cancerous lumps.areas of thickness or fullness.changes from previous self-examinations.fibrocystic masses.RATIONALE: Women are instructed to examine themselves to discover changes that have occurred in the breast. Only a physician can diagnose lumps that are cancerous, areas of thickness or fullness that signal the presence of a malignancy, or masses that are fibrocystic as opposed to malignant.The nurse is giving instructions to a client who is going home with a cast on his leg. Which point is most critical?Using crutches properlyExercising joints above and below the cast, as orderedAvoiding walking on a leg cast without the physician's permissionReporting signs of impaired circulationRATIONALE: Although all of these interventions are important, reporting signs of impaired circulation is the most critical. Signs of impaired circulation must be reported to the physician immediately to prevent permanent damage. The other options reflect more long-term concerns. The client should learn to use his crutches properly to avoid nerve damage. The client may exercise above and below the cast, as the physician orders. The client should be told not to walk on the cast without the physician's permission.

The nurse is providing breast cancer education at a community facility. The American Cancer Society recommends that women get mammograms:A.yearly after age 40.B. after the birth of the first child and every 2 years thereafter.C. after the first menstrual period and annually thereafter.D. every 3 years between ages 20 and 40 and annually thereafter.RATIONALE: The American Cancer Society recommends a mammogram yearly for women over age 40. The other statements are incorrect. It's recommended that women between ages 20 and 40 have a professional breast examination (not a mammogram) every 3 yearsWhen caring for a client who's being treated for hyperthyroidism, it's important to:provide extra blankets and clothing to keep the client warm.monitor the client for signs of restlessness, sweating, and excessive weight loss during thyroid replacement therapy.balance the client's periods of activity and rest.encourage the client to be active to prevent constipation. Dapat B sagot dto. RATIONALE: A client with hyperthyroidism needs to be encouraged to balance periods of activity and rest. Many clients with hyperthyroidism are hyperactive and complain of feeling very warm. Consequently, it's important to keep the environment cool and to teach the client how to manage his physical reactions to heat. Clients with hypothyroidism, not hyperthyroidism, complain of being cold and need warm clothing and blankets to maintain a comfortable temperature. They also receive thyroid replacement therapy, often feel lethargic and sluggish, and are prone to constipation. Therefore, the nurse should encourage clients with hypothyroidism to be more active to prevent constipation.A client underwent cataract removal with an intraocular lens implant. The nurse is giving the client discharge instructions. These instructions should include which of the following?Avoid lifting objects weighing more than 5 lb (2.27 kg).Lie on your abdomen when in bed.Keep rooms brightly lit.Avoid straining during bowel movement or bending at the waist.RATIONALE: The client should avoid straining, lifting heavy objects, and coughing harshly because these activities increase intraocular pressure. Typically, the client is instructed to avoid lifting objects weighing more than 15 lb (7 kg) not 5 lb. Instruct the client when lying in bed to lie on either the side or back.Avoid Bright light.A client receiving hemodialysis treatments has had surgery to form an arteriovenous fistula. Which of the following is most important for the nurse to be aware of when providing care for this client?A.Using a stethoscope for auscultating the fistula is contraindicated.B.The client feels best immediately after the dialysis treatment.C. Taking a blood pressure reading on the affected arm can cause clotting of the fistula.D.The client shouldn't feel pain during initiation of dialysis.RATIONALE: Pressure on the fistula or on the extremity can decrease blood flow and precipitate clotting. Auscultation of a bruit in the fistula is one way to determine patency. Typically, clients feel fatigued immediately after hemodialysis because of the rapid change in fluid and electrolyte status. Although the area over the fistula may have some decreased sensation, the needle stick is still painful.A 30-year-old teacher performs breast self-examinations monthly. Which of the following findings should she report promptly?Areolae that are bilaterally darkened in colorFreely movable masses that become tender before the menstrual periodMultiple tender, round masses in both breastsA hard, nontender mass in the upper outer quadrant of the left breastRATIONALE: Hard, nontender masses are associated with cancerous tumors. The upper outer quadrant is the most common site. Darkened areolae are associated with hormonal changes, such as those caused by pregnancy. Multiple tender, round masses in both breasts that become tender before a menstrual period indicate fibrocystic breast problems.Policy and procedure dictates that hand washing is a requirement when caring for clients. Which statement about hand washing is true?Frequent hand washing reduces transmission of pathogens from one client to another.Wearing gloves is a substitute for hand washing.Bar soap, which is generally available, should be used for hand washing.Waterless products shouldn't be used in situations where running water is unavailable.RATIONALE: Whether gloves are worn or not, hand washing is required before and after client contact because thorough hand washing reduces the risk of cross-contamination. Bar soap shouldn't be used because it's a potential carrier of bacteria. Soap dispensers are preferable, but they must also be checked for bacteria. When water is unavailable, the nurse should wash using a liquid hand sanitizer.

The nurse is evaluating a postoperative client for infection. Which sign or symptom would be most indicative of infection?Presence of an indwelling urinary catheterRectal temperature of 100 F (37.8C)Red, warm, tender incisionWhite blood cell (WBC) count of 8,000/mlRATIONALE: Redness, warmth, and tenderness in the incision area should lead the nurse to suspect a postoperative infection. The presence of any invasive device predisposes a client to infection but alone doesn't indicate infection. A rectal temperature of 100 F would be a normal expectation in a postoperative client because of the inflammatory process. A normal WBC count ranges from 5,000 to 10,000/ml.

The nurse is caring for a client with a fractured hip. The client is combative and confused, and he's trying to get out of bed. The nurse should:leave the client and get help.obtain a physician's order to restrain the client.read the facility's policy on restraints.order soft restraints from the storeroom.RATIONALE: It's mandatory in most settings to have a physician's order before restraining a client. A client should never be left alone while the nurse summons assistance. All staff members require annual instruction on the use of restraints, and the nurse should be familiar with the facility's policy.

The nurse is assessing a client for the risk of falls. The nurse should collect:gait and balance information.the agency's restraint policy.the family's psychosocial history.the client's dietary preferences.RATIONALE: Assessing the client's gait and balance helps determine the risk of falls. The facility's policy on restraints isn't relevant to a risk assessment for falls. Assessing the family's psychosocial history and the client's dietary preferences are important but not as important as gait and balance in relation to the risk of falls.

The nurse is administering sublingual nitroglycerin to a client. Immediately afterward, the client may experience:A.nervousness or paresthesia.B. Throbbing headache or dizziness.C. drowsiness or blurred vision.D. Tinnitus or diplopia.RATIONALE: Headache and dizziness commonly occur when nitroglycerin is taken at the beginning of therapy. However, the client usually develops a tolerance. Nervousness, paresthesia, drowsiness, blurred vision, tinnitus, and diplopia don't occur as a result of nitroglycerin therapy.The nurse is caring for a client receiving lidocaine I.V. Which factor is most relevant to administration of this medication?A. Decrease in arterial oxygen saturation when measured with a pulse oximeterB . Increase in systemic blood pressureC. Presence of premature ventricular contractions (PVCs) on cardiac monitorD. Increase in intracranial pressure (ICP)RATIONALE: Lidocaine drips are commonly used to treat clients whose arrhythmias haven't been controlled with oral medication and who are having PVCs that are visible on the cardiac monitor. blood pressure, and ICP are important factors but aren't as significant as PVCs in this situation.The nurse is developing a teaching plan for a client who has just been diagnosed with breast cancer. The nurse should include information about which medication?